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The Newsletter
of the
Association
of Anaesthetists
of Great Britain
and Ireland
INSIDE THIS ISSUE:
‘Erm… I’m the new
anaesthetic registrar –
what happens now?’
The price of a mile:
anaesthetics at the
Battle of the Somme
Too drugged to drive?
ISSN 0959-2962
JULY 2016
No. 348
Editorial
The life changing
POWER OF
ULTRASOUND
This issue contains a typically eclectic mixture
of articles. There is a school of thought that
‘History is more or less bunk’ (Henry Ford),
but some of us regard accurate history as
a foundation for the present, never to be
forgotten. So I was fascinated by Dr Ward's
AAGBI Graves of the Great project. There are
those among us who become engrossed
reading headstones in cemeteries; trying to
imagine the background to a person's life
brings reflection to the fore, especially about
the circumstances of those whose discoveries
have led to the current sophisticated specialty
in which we work. This would be an innovative
and suitably unusual but respectful way to design a varied touring
holiday. Sir Humphrey Davy's resting place in Geneva could add a
non-EU country to the list, or merely add to the existing non-EU itinerary,
depending upon circumstances.
We believe in the power of visualisation: the life changing
improvements to patient outcomes through ultrasound.
We share that belief and vision with the clinicians who
drive the capabilities and value of our products.
Collaborative, connected, cost effective
Our shared objectives are made real through an unremitting
focus on quality, patient safety and value.
The SonoSite family is built on four essential pillars: durability,
reliability, ease of use and education. Connect with our
community and bring the benefits of SonoSite excellence to
your patients.
SonoSite Edge II
As innovations lead, I wonder if you have invented something for our
Innovation and Technology prize? This will be presented at the January
2017 WSM London, for what we judge to be the best submission.
New apps feature often, but these require a CE mark for them to be
used commercially as they can be regarded as a treatment method for
patients, subject to the usual legal regulations. Feel free to submit your
ideas!
Lifeboxes for Rio has been tremendously successful so far, but a final
splash of cash would be tremendous, and take funds to the £96,000
target. This is so Lifebox can provide pulse oximetry for many places in
the developing world which currently don’t have this equipment, which
we here take for granted. Can you help? Please consider donating via
the AAGBI website – www.aagbi.org/lifeboxesforrio.
I hope you all have relaxing summer holidays and that no forecast for a
‘Barbecue Summer’ is made, as this can directly cause fluid overload in
burgers.
Gerry Keenan
Elected Member, AAGBI
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2422 04/16
Anaesthesia News July 2016 • Issue 348
05 Lifeboxes for Rio
08 ‘Erm… I’m the new anaesthetic registrar – what happens now?’
10 Anaesthesia Digested
11 Join us at the AAGBI’s
Winter Scientific Meeting
13 ‘You’re the doctor? I thought
you were the anaesthetist?’
08
14 The price of a mile:
anaesthetics at the Battle
of the Somme
16 The end of the dying tents in 1916: a centenary to celebrate
11
19 Scoop
21 Moving beyond audit: using
evidence and data to improve care
23 AAGBI Graves of
the Greats Project
We live in strange times. There is no money, we are repeatedly informed.
There seems, perhaps, to be no money to adequately fund the NHS, but
this apparent lack of cash should not affect what doctors feel they need
to request from governments. If this includes keeping patient services as
well as doctors’ pay and conditions acceptable, so be it. The alternative
is driving pay and conditions to perhaps unacceptable levels. Pay apart,
there is a principle at stake; that of being valued in one's employment.
SonoSite SII
03Editorial
06 Critical skills day
for medical students
Too Drugged to Drive is a stark reminder that perhaps warnings to day
surgery patients about not driving for 24 hours could often be insufficient.
We should check our local guidance for patients on the strength of
this article. And why would you not use an ECG in every patient under
anaesthetic? Here is the very place to glean such information.
We should continue to request – without guilt or reticence – what we
reasonably believe is necessary, for our patients and all doctors, in a
civilised manner.
SonoSite X-Porte
06
Critical Care Skills Day for students is a good pointer on how to organise
a practical day. It was clearly a great success and will have been a good
taster, perhaps encouraging students towards practising intensive care
medicine and/or anaesthesia.
For more information about these systems and SonoSite
excellence visit www.sonosite.com/uk or contact your local
customer service representative on 01462-341151.
SonoSite iViz
Contents
14
24 Too drugged to drive?
27 Particles
28 The Wylie Medal 2015
30 New membership services committee
19
31 Why isn’t there an ECG on the monitor? Take a guess
32 Your Letters
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London W1B 1PY
Telephone: 020 7631 1650
Fax: 020 7631 4352
Email: [email protected]
Website: www.aagbi.org
Anaesthesia News
Managing Editor: Upma Misra
Editors: Phil Bewley (GAT), Nancy Redfern, Richard Griffiths, Sean Tighe,
Mike Nathanson, Rachel Collis, Felicity Platt, Gerry Keenan and Elizabeth McGrady
Address for all correspondence, advertising or submissions:
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Email: [email protected]
Design: Chris Steer
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Email: [email protected]
Printing: Portland Print
Copyright 2016 The Association of Anaesthetists of Great Britain and Ireland
The Association cannot be responsible for the statements or views of the contributors.
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Anaesthesia News cannot be held responsible in any way for the quality
or correctness of products or services offered in advertisements.
3
£70,000
raised so far.
THANK
YOU!
The final sprint for
Lifeboxes for Rio fundraising
When I launched Lifeboxes for Rio back in September 2014,
I had no idea how successful this AAGBI fundraising
campaign would be. In almost two years, and with your help, I
am delighted to say that we have so far raised £70,000 towards
our £96,000 target to purchase 600 pulse oximeters; saving
thousands of lives around the world in countries where patients
are at risk of death from oxygen starvation during surgery.
I am immensely proud of what we have collectively achieved.
As we enter the final three months of the campaign (our final
sprint!), I encourage you all to get involved and support Lifeboxes for Rio in any
way you can, so that we deliver on our fundraising promise.
Dr Andrew Hartle, President, AAGBI
Saving lives in the developing world
The money you and many others have donated is already being put to good
use in the developing world.
Christian Medical Centre, Tanzania
Students from Kilimanjaro Christian Medical Centre,
Tanzania celebrated their graduation in May with Lifebox
pulse oximeters.
“We love our beautiful new oximeter gift and we cannot thank
you enough for your thoughtfulness.” Jende Japhary
“Feeling very proud of your gift to us. In my work place we
have no oximeters. This will be the first one. It means I can
enjoy my profession.” Manswab Sharif
“I have experienced such a difference. I can now enjoy my
work and feel equipped because I can minimise perioperative
anaesthetic complications and save countless numbers of
people’s lives with this Lifebox oximeter. Thank you so
much, it is a valuable treasure to me.” Joyce
AAGBI Foundation: Registered as a charity in England & Wales no. 293575 and in Scotland no. SC040697
Lifebox: Registered as a charity in England & Wales (1143018)
Anaesthesia
Anaesthesia News
News July
July 2016
2016 •
• Issue
Issue 348
348
Just the price
of a coffee
Imagine! If every AAGBI
member donated just £2.50
we’d raise £27,000. By donating
the price of a fancy coffee, you
can help us smash through
our fundraising target. And of
course, if you wish, you can
donate more.
www.aagbi.org/LifeboxesForRio
5
5 CRITICAL SKILLS DAY
FOR MEDICAL STUDENTS
concentrate on transferring ultrasound equipment and monitors on
the actual day. Obtaining sufficient good quality ultrasound machines
for a course is a challenge, as they are in constant use and cannot
be removed from clinical areas. We arranged to borrow the minimum
required - two (rarely used) older ‘I looks’ from Critical Care, and a
Micromaxx from the Postgraduate Clinical Skills Team. However, this
was greatly enhanced by Sonosite who sent a representative with five
of their latest ultrasound machines (X-Porte, S nerve and NanoMaxx)
on the day. These provided superior image resolution for teaching the
students and also proved a valuable learning experience for the trainers.
Finance was a major consideration and probably the area that gave us
the greatest concerns. Luckily the venue, models and simulators were
free and all instructors gave their time at no cost. Equipment was loaned
freely, clinical disposables consisted of borrowed teaching materials
from colleagues and time-expired/unused items gathered from clinical
areas of the hospital. Unlike postgraduate courses, where participants
can pay to cover costs through a study leave budget, medical students
are self-funding. This meant we could only charge a few pounds each
– and the society reserves were small. Catering costs for attendees
and instructors had to be considered as we felt it important to provide
refreshments for the limited break times. We therefore approached
several organisations for sponsorship and were fortunate to receive
donations from the Medical Defence Union and from the Medical
Protection Society on the provision that we advertised for them in return.
We also received a sum from the Sheffield University Students Union.
We had not anticipated the considerable expense – several hundred
pounds for two – of purchasing the commercially available replacement
vessels required in order to utilise the vascular access models. The cost
of these artificial vessels could not be funded from our limited reserves.
A ‘Blue Phantom’ silicone dummy was available from Sonosite but we
required more models for vascular access. Also there was no suitable
available model for arterial line insertion. Therefore, we decided to
substitute homemade phantoms – at a fraction of the cost – for the
vascular access stations. Manufacture of these is well described in the
literature and, after experimentation, we settled on a mixture of agar,
psyllium and cornstarch. Vessels were simulated with fluid-filled long
balloons (peripheral veins), latex tubing (arteries) and Penrose drains
(central veins). A cork tile covered wood platform base was used to
reduce ultrasound reflections from the supporting surfaces. These
performed adequately and were well received by both the students and
supervisors.
As medical students involved with the
Sheffield Anaesthetics and Critical Care
Society (SACCS) and the Acute Care and
Trauma Society (ACTSoc) we were looking
for a way to improve our knowledge of
practical skills associated with these
specialties. These societies were set up
and are run by medical students who have
an interest in the respective fields. We felt
the best way to improve our knowledge
was with a hands-on approach in a safe
simulated environment under expert
supervision, so we decided to organise an
extracurricular Critical Care Skills Day.
The whole process threw up some interesting challenges and
unanticipated difficulties but proved to be a worthwhile exercise. By
recounting our experiences, we hope to encourage others to set up
their own local critical skills days and offer practical advice.
board. Sheffield Medical School supported our efforts by saying that,
provided students made up the time they missed from placements
and got permission from their supervising consultant to attend the
day, they would allow students to miss placement to attend the day.
It was important to find interested and supportive consultants and
trainees who had experience in the provision of clinical skills and
knew where to recruit speakers, facilitators, source materials and
equipment. It was vital to the success of the event to maintain regular
communication with these supervisors to maintain the momentum,
offer support, confirm arrangements and check details.
Next we had to pinpoint a suitable location and date. It was important
to preview the possible venues with links to University and Sheffield
Teaching Hospitals and look into any costs, facilities and equipment
provision, access, parking and catering before the final decision.
We settled on the Undergraduate University Clinical Skills Centre – a
purpose-built facility with adjacent clinical rooms and a lecture theatre
all on the same floor. It had well equipped areas with simulation
models and the support of the undergraduate and postgraduate
clinical skills teams and technical support staff experienced in setting
up clinical scenarios. The clinical facilities and models would be free,
and being situated in the grounds of a large teaching hospital meant
there was sufficient parking and good public transport links.
We felt the best format for us would be a one day ’conference‘ that
commenced with introductory lectures on ultrasound principles and
critical care medicine followed by rotation through five practical stations
– airway management, ultrasound FAST scanning, ultrasound-guided
insertion of central/peripheral/arterial lines, trauma simulation and
sepsis simulation. The number of participants had to be optimised
so we settled on 30 – sufficient to make the effort worthwhile but not
too many to lessen the practical skills experience. The event was
predominantly advertised through social media (where many societies
conduct their business these days) and the Medical School message
6
It was essential to have access to the venue the day before the
course. With the help of support staff, it took several hours to organise
the stations, move furniture, trolleys, models, relocate equipment,
label the areas and display teaching materials. This meant we could
Anaesthesia News July 2016 • Issue 348
Despite widespread support and enthusiasm for this course we did
encounter some issues. In particular, the course was run on a weekday
when there was the inevitable problem of both students and supervisors
being released from scheduled duties to participate. Most consultants
require a good period of notice to arrange SPA time or study leave.
Many trainees had to wait until their duty rosters were published and
needed to seek permission from their attached consultants so could not
commit well in advance. We aimed to staff each station with a minimum
of two supervisors and were only able to confirm sufficient numbers
a few days before the course. When designing the course, we had
aimed to get 30 attendees but only 18 students from different stages
of training enrolled. The date was very close to the winter exam season
and this may have reduced attendance by senior students. Ultimately
the reduced numbers did not have a detrimental effect as student
participants received one-on-one tuition in many of the practical areas.
This was particularly rewarding for the more unfamiliar stations and for
less experienced students.
The best extracurricular activity
Overall the day was a resounding success. All of the students involved
seemed to find the day very enjoyable, with one student volunteering
that it was ‘the best extracurricular activity they had done at medical
school’ and exclaiming ‘Your hard work really paid off big time.’
From our point of view, we could not have been more pleased with how
the day worked out. Everything ran smoothly, albeit with some sessions
running over, and we felt the day was everything we hoped it could be.
On a personal level, we learnt to really appreciate the amount of time
and effort it takes to plan a day like this. It took a great team effort to
make the day come together. The experience of devising and running
this course will make it easier to replicate this skills day in the future.
We have learned a lot and now know how to make future events better.
Consideration could be given to additional teaching of spinal/epidurals
and ultrasound-guided nerve blocks.
There will be many other student anaesthesia, critical care and
emergency medicine societies who are interested in running similar
critical skills days and I hope we have demonstrated that this is a
practical and worthwhile undertaking. These courses serve to stimulate
students who already have an interest in critical skills and also introduce
students who have little knowledge of this branch of medicine to new
possibilities.
Martin McBride
Medical Student and Co-President of SACCs
David Edwards
Medical Student and President of ACTsoc
Kay Hawley
Retired Consultant anaesthetist
Northern General Hospital, Sheffield
Figure 1. a: peripheral vein phantom; b: central venous phantom; c: thin latex
modelling balloon; d: bionector Vygon 896.01; e: 12 in Penrose latex drain ½; f: 9 mm
latex tubing filled with red gel
Anaesthesia News July 2016 • Issue 348
Acknowledgements
We wish to thank Kay Hawley, Consultant Anaesthetist, and Chris Yap,
Consultant A&E, for their help and support in setting up and completing
this venture. We are very grateful for the participation of Sonosite, who
provided a good range of ultrasound machines and technical support
on the day. We wish to thank the Medical Defence Union, the Medical
Protection Society and the University of Sheffield Students Union for
their sponsorship. We also wish to thank all of the supervisors, clinical
skills staff and support staff who made this day possible.
7
‘Erm… I’m the new
anaesthetic registrar –
what happens now?’
So you’ve passed your Primary FRCA, had your interview and filled
out the mountain of paperwork for your new registrar job. What
happens now?
This is our account of the logistics of training, the common areas
which cause apprehension and some tips that we hope will help
others.
On-calls
Feel like you're about to be thrown in at the deep end?
The biggest and most startlingly obvious difference between being
a new registrar and a new core trainee is the absence of an easingin process. As a core trainee you have a 3–6 month preparatory
period before being deemed competent to go on the on-call rota
[1]; whereas, in the main, new registrars go straight on to a middlegrade on-call rota. This can be quite daunting, especially in some
hospitals where you may be the most senior anaesthetist in the
hospital! However, consultants are supportive and understanding of
this. When in doubt just pick up the phone and call the boss!
Intensive care and obstetric on-calls
You may never have done obstetrics or intensive care on-calls
before. Most hospitals are understanding of this and will make sure
you get some weekday supervised sessions first and also start you
with weekday on-calls, rather than straight into nights. Speak to the
rota co-ordinator, preferably before the rota is released, if you feel
you need a bit more experience before flying solo.
Just phone the intensive care registrar – they know everything!
Don’t they?
This assumption can be quite surreal, especially as these are often
complex patients. As with any referral, try to gain as much background
information as possible and look at investigations on your local
hospital systems. Always go and see the patient – the situation can
be very different from what has been relayed over the phone.
New found responsibilities
Solo lists
Solo lists can be challenging. Many new registrars will never have
done a completely solo list. They require a diverse skill set, most
notably organisation is key. Try to arrive early to see the patients and
make sure you are happy. You’ll need to allow time to talk through the
list with the named consultant supervising you and if you have any
niggling questions, always ask. Make clear in the morning theatre
team brief you are doing a solo list and where the nearest available
consultant is should there be a problem. You will not be as slick as a
consultant giving an anaesthetic, so don’t feel pressured into cutting
corners to speed up the list. Always take your time and be safe.
8
Supervising junior trainees
You may find yourself working alongside a core trainee, foundation
doctor or medical student when on-call or for an elective list. In
many ways you are ideally placed to help teach and it’s nice to have
company. If supervising a trainee from a distance, always make sure
that he or she is comfortable with the work and make clear how you
can be contacted or where you will be. When on-call, touch base
with your team often and encourage them to keep you informed as
this can help take away some of the potential stress of supervising.
Remember that ultimately you are all supervised by the consultant
on-call and that they too should be informed of challenging situations
or anything you are unsure of.
Intermediate training
Exam, exam, exam
Start thinking early about when you want to sit the Final Written and
thereafter the Final SOE. Each component is only sat twice per
academic year [2,3] and you require both components in order to
progress to ST5 [4].
Plan your modules (+ some contingency time)
Two years of intermediate training [4] can fly by unless you plan
ahead as to when and where you want to complete your modules.
There may also be a module or two which you are unable to complete
in the allocated time period. This can arise secondary to a wide array
of issues, i.e. failure to complete the required workplace-based
assessments and unplanned leave (e.g. sick or compassionate
leave).
The future
I’ve passed the Final FRCA, what now?
There is certainly a temptation to take things easy for a while having
passed the final FRCA. But before you know it, another three years
has gone by and applying for a consultant post is imminent so it
is definitely wise to plan ahead. In years ST5–7, higher [5] and
advanced level [6] training are undertaken with a view to preparing
for independent practice and developing your sub-specialty
interests. Speaking with your senior peers and consultants early on
is prudent; they may have knowledge or experience of the advanced
training module, fellowship or research you are considering. Do also
persevere with audits, quality improvement projects and attending
courses and conferences.
accommodate sub-specialty training and research both within (as advanced
training) and out of programme. It is worth noting that the various steps in
approving an OOPT/E or OOPR [7] can take several months. If intensive
care, pain medicine, paediatrics or other sub-specialties appeal it may also
be desirable to gain experience out of region or indeed abroad. Just when
you thought all your days of revision were over, be aware that training in pain
or intensive care requires further exams. You might consider undertaking an
accredited qualification in a sub-speciality area or even a higher qualification
in medical education or management. Teaching as a faculty member or even
developing a new course may provide a great CV boost.
Hang in there…the end is in sight!
When the going gets tough, keeping sight of your end goal is important
but also remembering why you embarked on training in anaesthesia will
hopefully spur you on! Being increasingly versatile and an experienced pair
of hands makes you a valued member in your department and having an
element of self-direction in your training should make your work fulfilling. The
prospect of reaching the end of the tunnel is perhaps a little daunting but
exciting too.
Top Tips
1. Ask for help
This cannot be emphasised enough. You are not expected to know
everything. Consultants and senior trainees do understand what it is
like to be a junior registrar
2.Have confidence in your abilities
It may seem obvious, but no one handed you your training number. You
worked really hard to get it, have confidence that you deserved it
3. Keep in touch with other new registrars
Try to make contact with other new registrars. Similar to when you were
a core trainee [8], your peers can be great sounding boards for all your
calamities
4. Think about future directions early
Time flies having passed the Final FRCA; think early about developing
your interests and how you might stand out from the crowd
Satinder Dalay
ST5 Anaesthetics
Naginder Singh
Consultant Anaesthetist
University Hospitals Birmingham NHS Foundation Trust
Acknowledgement
We would like to thank Emma Plunkett for her continual support and
invaluable help in preparing this manuscript.
References
1.
2.
3.
4.
5.
6.
Direct your further training…
The compulsory higher training modules are an ideal opportunity
to expand upon your existing knowledge and experience and to
gain confidence in undertaking increasingly independent practice.
There is usually ample provision within most training programmes to
Anaesthesia News July 2016 • Issue 348
7.
8.
The Royal College of Anaesthetists. Initial Assessment of Competencies (IAC). http://www.
rcoa.ac.uk/training-and-the-training-programme/initial-assessment-of-competencies-iac
(accessed 30/03/16).
The Royal College of Anaesthetists. Final FRCA Written. http://www.rcoa.ac.uk/examinations/
final-frca-written (accessed 30/03/16).
The Royal College of Anaesthetists. Final FRCA SOE. http://www.rcoa.ac.uk/examinations/finalfrca-soe (accessed 30/03/16).
The Royal College of Anaesthetists. Intermediate Level. http://www.rcoa.ac.uk/node/208
(accessed 30/03/16).
The Royal College of Anaesthetists. Higher Level. http://www.rcoa.ac.uk/node/209 (accessed
30/03/16).
The Royal College of Anaesthetists. Advanced Level. http://www.rcoa.ac.uk/the-stages-oftraining/advanced-level (accessed 30/03/16).
The Royal College of Anaesthetists. Training Out of Programme (OOPE and OOPT).
http://www.rcoa.ac.uk/careers-training/oope-and-oopt (accessed 30/03/16).
Moore J. Surviving Core Training in Anaesthesia. Anaesthesia News 2012; 301: 19.
Anaesthesia News July 2016 • Issue 348
9
Join us at the AAGBI’s Winter
Scientific Meeting (WSM London)
Digested
July 2016
AAGBI guidelines: the use of blood components and their alternatives 2016
Klein AA, Arnold P, Bingham RM, et al
The safe and effective practice of transfusion medicine is one of the
key responsibilities of anaesthetists, and the rapid development of
the field means that these wide-ranging guidelines are both timely and
necessary, and build on previous publications by the AAGBI. They
are essential reading, as they include practical and workable advice on
all aspects of blood and transfusion that are of importance to us, and
will help to ensure this precious resource is widely used to improve
patient outcomes and safety.
They remind us all of the need for correctly transfusing and ensuring
the traceability of blood that we have given, and of ensuring that we
have procedures in place for when this might be difficult, such as in
unidentified patients. Most will be familiar with transfusion thresholds
of 70 g.l-1 and major haemorrhage protocols, but will welcome
guidance in special situations such as haemato-oncology and cardiac
patients. Many, too, will be grateful to have access to what to do
when confronted by a patient who is on the latest novel anticoagulant
that you’ve never heard of! Also welcome is the inclusion of advice
for special situations, including critical care and paediatrics, and the
specific guidance for the use of blood component therapy means
you’ll never feel like you just have to pick a number again.
London welcomes
the anaesthesia
profession
You’re invited to submit an abstract for poster presentation at WSM
London 2017. The deadline to submit an abstract is Wednesday
31 August 2016. A preliminary review of abstracts received will
determine which abstracts will be accepted for poster presentation. If
accepted, your abstract will be published in a fully referenceable online
supplement to the Anaesthesia journal. Authors of the best poster(s)
will be awarded ‘Editors’ Prizes.
MacDougall-Davis SR, Kettley L, Cook TM
The users of the system also rated the system as significantly more
useful than SBAR, with 96% of participants preferring the ‘Traffic
Light’ tool, and the authors go on to suggest the adoption of this
communication tool as standard practice for the anaesthetic teams.
They make a compelling argument that while SBAR may be better
than no tool, adoption and compliance with it has been variable
in the healthcare setting, and it is difficult to show demonstrable
benefits from it. It is also usually used face to face, rather than when
communication is via an intermediary, and there are no studies to
support its use under these circumstances.
NELA Prize
Delegate registration is now open for the AAGBI Winter Scientific
Meeting (WSM London), which takes place 11-13 January 2017
in central London at the QEII Centre Westminster. Even though
we’re in the midst of summer, plans are already underway for
what is set to be the AAGBI’s biggest and best WSM London
to date.
•
Don’t judge a book by its cover, don’t judge a study by its abstract. Common
statistical errors seen in medical papers
Choi SW
Well done, time for one more quick abstract to keep you up to
date…but does it, and should you believe what you read in it? In
this continuing series of statistical articles, the authors caution against
this all too common habit, and carefully consider perhaps the most
basic aspect of studies upon which we base many of our assumptions,
namely that the two groups we are studying are the same, other than
for the intervention of interest. We are reminded that six assumptions
Each year at WSM London the AAGBI celebrates, recognises and
awards the work of individuals and teams within the anaesthesia
profession.
Abstract Submission
The ‘go-between’ study: a simulation study comparing the ‘Traffic Lights’ and ‘SBAR’
tools as a means of communication between anaesthetic staff
We’ve all been there – stuck in theatre on your own with a situation
that is unravelling. You don’t want to tell the ODP to go and get help,
because you need their help right now, and yet you need to summon
assistance from a colleague, so you ask the HCA to help out. What is
the best way to do this? Until recently we’d have been taught to use
the SBAR tool to effectively communicate what you need, but is it in
fact the best way? These authors challenge this view in this simulation
study, and show that by using a ‘Traffic Light’ system they were able
to deliver information better, with less degradation of information,
improved clarity, and also less time taken to deliver the message.
Your time to shine
must be satisfied before using the t test, which along with the Chi
squared test is the most commonly used in the medical literature –
investigators usually only describe one of these assumptions, and
the authors show us how to manage and appraise the data we are
presented with. As ever, before changing our practice based on
published research, we must satisfy ourselves that the statistical
methods were valid, and support the conclusions drawn.
N.B. the articles referred to can be found in either the latest issue of Anaesthesia or on Early View (ePub ahead of print)
A.E. Vercueil
Editor, Anaesthesia
•
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•
•
•
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•
Over 1000 delegates representing the anaesthetic
profession in the UK, Ireland and internationally
A first-class and diverse Scientific Programme
High-profile keynote speakers, including Baroness Prof
Susan Greenfield, Oxford; Dr Andy Bodenham, Leeds and
Prof Justiaan Swanevelder, Cape Town
A dedicated Core Topics day
Practical workshops
Poster presentations and awards (see across)
Popular industry exhibition, showcasing the latest
technology and services
A fun social programme and more
And of course, the usual early-bird booking rates for AAGBI
members apply. To view the Scientific Programme and
to book your early-bird place at WSM London 2017 visit
www.wsmlondon.org
NELA will also be sponsoring a Trainee poster prize at the WSM London
2017. This prize will be for the best poster that uses your hospital's
NELA data to bring about an improvement in care.
To find out more and start planning your abstract submission,
visit www.wsmlondon.org/content/abstract-submissions
AAGBI
Innovation Award
The annual AAGBI Prize for Innovation in Anaesthesia, Critical Care and Pain.
The AAGBI Prize for Innovation 2017 promotes innovation in
anaesthesia and intensive care. The 2017 award is open to all
anaesthetists, intensivists and pain specialists in Great Britain and
Ireland and will be presented at WSM London 2017. The emphasis is
on new ideas contributing to patient safety, high quality clinical care
and improvements in the working environment.
The deadline to apply for the AAGBI Innovation Award is Friday 30
September 2016. Find out more about the AAGBI Innovation Award
visit www.aagbi.org/innovation
Find out more – visit www.wsmlondon.org
Anaesthesia News July 2016 • Issue 348
11 ‘You’re the doctor? I thought
you were the anaesthetist?’
The Obese Parturient
Dr C Elton Leicester Royal Infirmary
Obstructive Sleep Apnoea in
Pregnancy: Diagnosis & Management
Dr L O’Brien
University of Michigan Thromboelastrography on the Labour
Ward
Dr J Bamber Cambridge University Hospitals
Resuscitation of the Pregnant Woman
– findings from UKOSS
Dr P Sharpe Leicester Royal Infirmary
You’ve just spent the last 25 minutes with Betty before her right
hemicolectomy. You introduce yourself, ‘Good morning, my name is
Joe Bloggs, I will be your anaesthetist today’. You take your time in
developing a rapport and helping Betty feel at ease with her upcoming
procedure and postoperative care. At the end of the consultation you
ask her if she has any questions. She politely says, ‘When is the doctor
coming to see me?’. You smile. Do you insist that you are a doctor and
is she in fact referring to the surgical team? Who in actual fact give
up their doctor title on completion of the MRCS. Or do you ignore her
innocent (mildly offensive) obliviousness?
But there is some truth behind her misconception. Across the
developing world the majority of anaesthetic providers are not doctors.
In Uganda, for example, the ‘anaesthetists’, who are differentiated
from the ‘anaesthesiologists’ by a medical degree, have to complete
an allied health degree (nursing or midwifery) and then an anaesthetic
diploma. They are then qualified to practice independently as nonphysician anaesthetists (NPAs). Tanzania has a similar system. The
USA has the concept of nurse anaesthetists who work under the
supervision of a physician, but are licensed to do everything a doctor
can do. Sweden also has a similar concept.
Through a Glass Darkly: role of
ultrasound in Obstetric Anaesthesia
Dr D N Lucas Northwick Park Hospital
Further there is little incentive for the anaesthesiologists to train the
NPAs. If they do so, they risk losing the access to private practice. In
Uganda, there are no entry criteria to enrol for the NPA course, hence
there is a very large variation in ability and motivation between the
students. This, coupled with the conflict of interest, has led to a large
chasm in the knowledge base between the two groups, which has
lead to some animosity.
It is clear to see anaesthesia is not given the same priority in the
developing world. Outside the large national hospitals, you will
often find no qualified anaesthesia provider and thus anaesthesia is
provided by the surgeon in the form of a spinal or ketamine, with little
or no monitoring. Hence, where is the need for a fully qualified doctor
to be solely responsible for this? Anaesthetic-related mortality has
been quoted as high as 1/500 in Togo, while in the UK it is 1/185,000
[1]. The availability of facilities, drugs and expertise varies hugely, from
consultant-led care to student NPAs working night shifts in obstetrics
and running lists solo. The financial advantages of NPAs are clear
and in the developing world there are no other options. The debate
has been raging for years in the USA. Nurse anaesthetists need a
physician to be present during induction and emergence and at any
critical steps, but not in between. It seems to be only financially viable
if there are at least three nurses working under the supervision of a
physician. Once you start increasing the ratio, the workload for the
physician becomes more difficult to manage.
Safety in Connections
Dr P Sharpe Leicester Royal Infirmary
Decision Making – can we do it better
Mr K Hinshaw Sunderland Royal Hospital
GA for CS: a balanced view
Dr R Russell John Radcliffe Hospital
Consultants
£120
Conveniently, Mr Watts the surgeon arrives just on cue. Betty instantly
recognises him and smiles. You take a step back and almost blend into
the background, safe in the knowledge that all the years of experience
from medical school until this point have given you the skill, knowledge
and ability to provide a safe anaesthetic, something that is considered
a luxury in the developing world.
Trainees
£50
Mohammed Jawad
ST3 Anaesthetics, North West London Deanery
Fees:
Staff Grades
5 CPD Points
Applied For
To become qualified as an anaesthesiologist in both Uganda and
Tanzania, following your medical degree and internship (equivalent to
FY1), you enter a 3-year programme which leaves you fully qualified to
practice independently. This is a total of nine years from the beginning
of medical school (in contrast to the UK where it is a minimum of 14
years), but one must factor in that the working hours in Uganda are
almost double the limited European working time hours that we comply
to. The NPAs by contrast will study for a minimum of three years in
Tanzania (two years allied health diploma and one year anaesthetics)
and four years in Uganda (two years allied health and two years
anaesthesia). There is no formal differentiation between the two; a
NPA is qualified to do exactly what the anaesthesiologist is licensed to
do. The system relies on a NPA referring a more complicated case to
an anaesthesiologist, but is not legally obliged to and, often, there is
no physician available. The final legal responsibility lies with the most
qualified person involved with the operation, which is the surgeon,
even if there was to be an anaesthetic blunder.
Midwives
£100
£40
Jonathan Harris
Consultant anaesthetist, Northwick Park Hospital
Reference
1. Walker IA, Wilson IH. Anaesthesia in developing countries – a
risk for patients. Lancet 2008; 371: 968–9.
Anaesthesia News July 2016 • Issue 348
13 The price of a mile:
anaesthetics at the Battle of the Somme
In July 2016, it will be 100 years since the start of the Battle of
the Somme, which took place from 1 July to 18 November 1916.
It was a series of fierce battles fought on the British and French
fronts in the area of the river Somme and the river Ancre in Picardy
in northern France. It must not be forgotten that 1 July was the
132nd day of the Battle for Verdun where the German army had
tried to bleed the French army dry: that was one of the reasons for
the Battle of the Somme,
The appalling tragedy of the Somme is well known. At 7.30 am, 14
British Divisions along an 18 mile front, each soldier carrying up to
60 lbs of equipment, climbed out of the trenches, went ‘over the
top’ and walked slowly towards enemy defences they expected to
find annihilated by the week long bombardment by 4,350 guns.
Instead they were massacred by enemy gunfire. In total, 30,000
were killed or wounded in the first hour, and 50,000 by noon. At
the end of the first day, 21,000 were dead and 35,000 wounded;
14,000 were taken to Casualty Clearing Stations (CCSs).
The wounded were evacuated from where they lay in the open (or
from where they had lain for up to four days in shell holes), first by
the stretcher bearers, then to regimental aid posts, then dressing
stations and by ambulance convoys to one of the 14 CCSs, before
evacuation to base hospitals on the north-west coast of France or
by hospital ship to the UK. The medical services were faced with
an unprecedented number of casualties.
A CCS was the first medical unit a wounded man could reach
where surgery and nursing could be provided. Serious cases were
held as long as necessary, the rest being evacuated as quickly as
possible to the base hospitals or to the UK.
The sites for the CCSs had been selected and prepared prior to
the battle. The sites had to be close enough to the front to receive
casualties by motor ambulance from the dressing stations, but far
enough back to be safe from shell fire and near a broad gauge
railway line so that those who could be moved could be quickly
evacuated. For example, No 36 and No 38 CCSs were along the
Amiens–Albert line of the railway at Heilly. Fourteen CCSs were
available to the 4th Army, which bore the brunt of the attack. The
CCSs were grouped in pairs at each site, receiving admissions in
rotation so as to spread their workload.
In 1916, CCSs had a surgical team consisting of a surgeon, an
assistant, an anaesthetist and a nursing sister with operating
theatre experience. There is no indication in the official or unofficial
histories of any particular training for the anaesthetist.
No 36 CCS at Heilly received 1,050 wounded on 1 July, 1,533
wounded on 2 July and 3,040 wounded in the first three days of
the battle. No 29 CCS at Gézaincourt received 5,346 wounded on
2 July and 11,186 in the first three days. The strain on the CCSs
was enormous. The total number admitted to the CCSs from July
to November 1916 was about 600,000, and 30,000 operations
were performed. The French Medical Services of the French 6th
Army, evacuated 105,672 wounded from their field medical units
from July to November 1916.
Lessons had been learnt from the earlier battles of the War of
the severity of wounds caused by bombs and shells in trench
warfare, which were so different from those of previous conflicts,
and medical preparations for the Somme Battle gave the first
opportunity for surgery on a large scale. The anaesthetists and
surgeons were then faced with men covered with mud, severe
injuries and suffering from exposure. Theoretically they were fit,
as most were category A, but many had irritable chests due to
smoking. The Australians, not being accustomed to the European
climate, were particularly prone to chest problems.
The general anaesthetics used for surgical operations were ether
and chloroform by the open method, using a Schimmelbusch
mask, or with Shipway’s warm ether apparatus and oxygen, ethyl
chloride and nitrous oxide and oxygen. Stovaine in a 5% solution in
glucose was used for spinal anaesthesia, and local infiltration was
achieved using Novocaine. Ether and chloroform for anaesthetic
purposes were required in such enormous quantities that special
facilities were granted to the limited number of manufacturers of
these drugs for augmenting their plant in order to increase the
output to meet requirements. Nitrous oxide and oxygen required
a large number of special cylinders, which were difficult to supply
because of demand for steel in munitions. Oxygen was supplied
to home hospitals by BOC (British Oxygen Company) and in
France the cylinders were filled by French firms.
14 Location of medical units
Anaesthesia News July 2016 • Issue 348
Anaesthetic Equipment
Each Military Hospital which included the CCSs had the
following minimum anaesthetic outfit in an Operating theatre.
Bottles, drop (4 oz)
3
Forceps, tongue (Guy's)
1
Forceps or holders, sponge
2
Gags, mouth (Mason's and Doyen's) Inhaler ether, Clover’s large bore, with two face pieces,
large and small with nitrous oxide apparatus
combined set
2
Inhaler, chloroform, Junkers (Buxton's)
1
Masks, Schimmelbusch's
2
Oxygen cylinder and fittings set
1
Props, mouth
3
1
The battle ended on 18 November 1916 due to the incessant
rain which turned the chalk fields into a quagmire. The furthest
line of advance was only seven miles forward of where it had
been on 1 July 1916. The number of British killed in the Battle
of the Somme was 419,000.
Jean Horton
Retired anaesthetist and former President
of the History of Anaesthesia Society
Bibliography and Further Reading
1. Macpherson WG. The Somme Battles of 1916. Ch II in
Official History of the Great War. Medical Services, General
History. Vol III. HMSO: London, 1924.
2. Macpherson WG. The development of Casualty Clearing
Stations and front-line Surgery in France’. Ch XI in Official
History of the Great War. Medical Services. Surgery. Vol I.
HMSO: London, 1922.
3. Crampton HP. Anaesthesia. Ch IX in Official History of the
Great War. Medical Services. Surgery. Vol 1. Ed by WG
Macpherson. 1922. HMSO. London, 1922.
4. Horton J. The Battle of the Somme 1916. Anaesthetics
at Casualty Clearing Stations. The History of Anaesthesia
Society Proceedings 1998; 24: 49. http://www.histansoc.org.
uk/uploads/9/5/5/2/9552670/volume_24.pdf
Anaesthesia
Anaesthesia News
News July
July 2016
2016 •
• Issue
Issue 348
348
The area of advance (the price of a mile) taken from The First World War by John Keegan.
ANAESTHESIA
HERITAGE
CENTRE
There will be an exhibition about the Battle of
the Somme in the Heritage and Museum Centre
in September 2016. For further details visit:
www.aagbi.org/heritage
15
15 C
M
Y
11th West of England
Anaesthesia Update
CM
MY
CY
The end of
the dying
tents in 1916:
a centenary to
celebrate
if not hostile military medical establishment. His preferred choice of
transfusion technique was always to use 20 ml glass syringes, internally
coated with sterile paraffin wax, to delay clotting and aspirate from the
donor and then simply inject into the patient through peripheral lines. At
that time, the Kimpton tube was also popular, where venous access was
obtained by a cut down, and Unger’s two way tap/stop-cock was also
used to allow aspiration and injection for the single-handed clinician.
CMY
K
11th West of England Anaesthesia Update Conference
Based in Chalet Hotel St Christoph Austria
Talks cover a wide range of topics in anaesthesia, pain and ICM
15 CPD points RCOA
Flights from Bristol, Gatwick, Southampton and other airports nationwide
All grades of Anaesthetist from everywhere welcome.
th
rd
16 – 20 January 2017
St Christoph am Arlberg (nr St Anton), Austria
ANAESTHESIA NEWS
Visit: www.weauconf.com
Anaesthesia News now reaches
over 11,000 anaesthetists
every month and is a great
way of advertising your course,
meeting, seminar or product.
Anaesthesia News
is the official magazine
of the Association of
Anaesthetists of Great
Britain & Ireland.
CALL
NOW FOR
A MEDIA
PACK
For further information on advertising
Tel: 020 7631 8803
or email Chris Steer:
[email protected]
www.aagbi.org/publications
Dr Les Gemmell
Immediate Past Honorary Secretary
21 Portland Place, London W1B 1PY
This is the story of the doctor who
brought blood transfusion to the
Western Front, and the end of the dying
tents transforming resuscitation and
triage during the First World War.
July 1916 is the centenary of the Battle of the Somme where, from 1
July to 18 November 1916, over a million men were killed or wounded
in a senseless slaughter and hopeless attempt to break the deadlock
of trench warfare – at the end of which the front line stayed virtually
the same. However, there is another centenary which we should
recall with more hope at this time. On 8 July 1916, just a week into
the Battle of the Somme, Captain Dr Bruce Robertson, a Canadian
volunteer doctor from Toronto, had his paper The Transfusion of
Whole Blood: A suggestion for its more frequent employment in war
surgery published [1]. This was to mark a pivotal change in Royal
Army Medical Corps (RAMC) protocol for how casualties were to be
resuscitated on the Western Front. Blood transfusion was now to be
encouraged.
In 1914, at the beginning of the First World War, blood transfusion
was not included in the RAMC treatment protocol for a casualty with
shock. A casualty with shock was thought to be suffering from an
over stimulation of the vasomotor centre and that the best treatment
was morphine to reduce the effect of stimulation, warm tea, warming
of the patient with hot water bottles, blankets and perhaps a small
volume of intravenous saline. The Casualty Clearing Stations,
situated about six miles behind the Front, were the closest medical
facilities where surgery could be undertaken safe from the shelling
and the protocol initiated. However, if the blood pressure remained
low, any form of surgery was known to be poorly tolerated and the
casualty was often transferred to the Moribund Ward, also known
as the Dying Tents, where they would most likely expire quietly with
compassionate but useless treatments.
From our vantage of hindsight it is not surprising that giving spinal
anaesthesia to a casualty with severe anaemia or haemorrhagic
shock, or even to administer deep ether or chloroform probably
without added oxygen would be poorly tolerated if not lethal. This
would be before the introduction of Dr Geoffrey Marshall’s better
designed anaesthetic machine using the more cardiorespiratorystable technique of nitrous oxide and oxygen [2]. Therefore,
conservative management was thought to be the best that could
Captain Dr Bruce Robertson
be done when the initial protocol failed, as it was most likely to do.
However, Dr Bruce Robertson had experience and insight that was to
drive him to challenge the RAMC early protocol and to work tirelessly
to convert his medical colleagues to use blood as a resuscitating
agent. His previous experience set him in a unique position to be the
pioneer at the early stages of the First World War.
He qualified in medicine from Toronto Medical School in 1909 and
did his internship in surgery at Toronto Hospital for Sick Children.
He then moved to the Bellevue Hospital in New York where he
trained in paediatric and orthopaedic surgery and then later at the
Children’s Hospital, Boston. He returned to Toronto in 1913. During
his time in the USA he saw at first hand the pioneering work of the
small group of American doctors who were revisiting the value of
blood transfusion, which Europe had then abandoned. This was
the fortuitous experience that made him the ideal clinician to make
the changes needed when he was to see scores of war casualties
suffering from haemorrhagic shock and severe anaemia on the
Western Front in 1915. New York and Boston at the beginning of
the 20th century were the medical centres leading the research into
blood transfusion practice, with Edward Lindeman at Bellevue and
Richard Lewisohn and Lester Unger at Mount Sinai. Robertson was
duly inspired and on his return to Toronto is reputed to have been the
first clinician to give a blood transfusion in that hospital.
When war was declared in August 1914,
Robertson, then a surgeon at the Toronto
Hospital for Sick Children, was among
the first Canadians to volunteer to join the
Canadian Army Medical Corps. After some
administrative delays, in 1915 he was to find
himself embedded into the RAMC on the
Western Front and dealing with the horrors
of the war casualties in base hospitals and
Casualty Clearing Stations. It was here
he was to struggle tirelessly, often on a
case by case basis, to demonstrate his
faith in blood resuscitation to a sceptical
Anaesthesia News
News July
July 2016
2016 •• Issue
Issue 348
348
Anaesthesia
Kimpton
tube
During his time in France it is recorded that he had numerous episodes
of sickness for what was described as ’flu‘. In retrospect it is possible
that his personal medical history of frequent breakdowns could be
interpreted as a stress response, not only to the military trauma he was
dealing with, but also to the burden of knowledge he carried of how
serious haemorrhagic shock and severe anaemia mortality could be
easily prevented. It is a testament to his dedication, personality, and
powers of persuasion that by 1916 he had won over many senior
members of the medical military establishment and, with assistance
from his superiors, was able to publish his seminal paper just one week
after the start of the Battle of the Somme. It was difficult when working in
Casualty Clearing Stations and base hospitals to collect follow up data
on his patients as they were quickly referred down the line or back to
England to make space for new casualties. His unique method of data
collection was to give his patients addressed envelopes for them to
post details of their clinical progress back to him. His poor health finally
resulted in him being invalided back to Canada in February 1918.
The USA entered the war in April 1917 and when their medical teams
arrived in France they consolidated the practice of blood transfusion,
which by that time had been accepted by the RAMC. It was the
Canadians and especially Bruce Robertson who had made the initial
pioneering breakthrough that was to lead to the global acceptance of
the value of blood transfusion.
Sadly Bruce Robinson died in 1923 at the age of 37 from the Toronto
flu epidemic, leaving a widow and two young children. For decades
after the First World War his rightful pioneering place in the history
of blood transfusion was much neglected as his personal testimony
was missed due to his untimely death. But the more recent scholarly
historical research by Kim Pelis [3] has given him the credit which he
justly deserves and has given us this historical centenary we can all
celebrate.
Ray Towey
St Mary’s Hospital Lacor Gulu, Uganda
References
1.
2.
3.
Robertson LB. The Transfusion of Whole Blood: A suggestion for its more frequent
employment in war surgery. British Medical Journal 1916; 2: 38–40.
Marshall G. The Administration of Anaesthetics at the Front. British Medical Journal
1917; 1: 722–5.
Pelis K. Taking Credit: The Canadian Army Medical Corps and the British conversion to
blood transfusion in WW1. Journal of the History of Medicine and Allied Sciences 2001;
56: 238–77.
17 History of
III
Anaesthetists
flock to form the
Peri-operative
Physicians’
Consultants
Club (P2C2)
Perioperative Medicine
Education Fellowship: UCL
A rare opportunity for an Anaesthetist wishing to
develop a career in medical education.
In collaboration with HCA International, UCL
Perioperative Medicine Group hosted in the Division
of Surgery & Interventional Science are pleased to
invite applications for this high-profile post
from February and August 2017.
•Join an international faculty of experts
•Conceptualise, design and develop ground
breaking education
•Undertake a higher degree from a
world-class university
The appointment will be for one year in the first instance,
but may be extended subject to satisfactory appraisal
and progress. The group would actively support fellows
extending their fellowship to two or three years
with the aim of attaining MD (Res) or PhD.
Candidates will need to have:
•GMC registration and license to practice
•Advanced Life Support provider
•FRCA or equivalent
Candidates are encouraged to make an appointment
to talk over a potential application with programme
lead Dr David Walker by email [email protected]
To apply please send a CV and covering letter
to [email protected]
Senior Consultant Peri-operative Physician Professor Julian de-la-Bicpen
explained in an interview with Scoop that anaesthetists were moving on to
much more vital clinical tasks than simply looking after patients in theatre.
periop_ad_0516.indd 1
18/05/2016 11:54
Sydney and Melbourne, Australia
January 2013
History of
Anaesthesia
Edited by
Michael G Cooper
Christine M Ball
Jeanette R Thirlwell
by our correspondent Scoop O’Lamine
VIII
Proceedings of the
8th International Symposium
on the History of Anaesthesia
The Proceedings of
the 8th International
Symposium on the
History of Anaesthesia
is now available.
A$pl8us0
age
post
Covers history of anaesthesia, intensive care, pain
medicine and resuscitation. Over 100 chapters and
authors, 800 pages and illustrated.
He explained that when he led a national specialty profile planning
group of anaesthetists, they looked at the job plans of anaesthetists
and compared them with senior physicians. Following a period of
Public House methodology it became clear that anaesthesia in its
current form was considerably more hands-on, routinely involved
direct patient care rather than ‘consulting’ as with physicians and also
involved exhausting out-of-hours care (even at night).
‘Clearly something was wrong. Not only are physicians working more
efficiently by standing back and directing their teams’ activities, but by
using this approach of stepping back from the heat of the direct patient
interaction, they are able to preserve their contribution by working as
senior super-specialists dispensing advice from their resource laden
offices or trains. This innovative approach has long been recognised
by the NHS in the ACCEA system.’
So, explained Julian, by finally gaining an understanding of the need
to emulate our physician colleagues for true NHS patient safety, a new
anaesthesia specialty – Peri-operative Medicine – has been developed,
which will be staffed by senior anaesthetists. Many of these seniors
have selflessly agreed to alter their day to day hands-on work to act
more as super specialists. ‘Sit in a resourced location, immediately
available for peri-operative consultation by younger colleagues who
can simply arrange appointments with us.’
Michael G Cooper
Christine M Ball
To order please complete the form found on the Books
page in the Publications section of www.asa.org.au.
There are many high impact patient-facing sessions including ward
rounds, clinics (pre and post anaesthesia) and CPEX assessments.
The average patient interaction is classified as Major/Complex Major
and an hour per patient is usually required.
For further information, email [email protected].
In order to develop and train this new specialty, the leaders have
formed a Club – the Peri-operative Physicians’ Consultants Club
(P2C2). Members of the P2C2 are nominated by existing members
and assessed for suitability from their contribution to the peri-operative
medicine network. If accepted as a member of the club, after one year
of service, payment of a lifetime membership, attendance at annual
congress and following reputational reports from other members, the
title of Professor is awarded.
Australian Society of Anaesthetists
Anaesthesia News July 2016 • Issue 348
The major role of the club will be
for self-promotion of the specialty and
the Professor members, and the chosen motto is ‘Deliver, develop,
manage, research and train’ – which are the cornerstones of the
activities planned.
It is envisaged that P2C2 will develop guidelines using passive
reflection and activated discussionary techniques first pioneered by
Professor Rubik Cube, one of the early members. This approach is
unusual as guideline development members sit in ultra-comfortable
recliners, eyes closed and suggest to each other ways of dealing
with difficult peri-operative issues. It is believed that this technique
developed from the ancient art of physicians making guidelines using
the ‘as they went along’ technique.
‘Too much extraneous noise and needless debate merely destroys
deeper reflections. Literature and the p value are pointless for
folk as experienced as us’ explained Professor Cube in a lengthy,
uninterrupted interview where he was covering two anaesthetists
providing anaesthesia for day surgery. ‘No such thing as a minor
anaesthetic – we won’t fall for making that mistake!’
Initial estimates by Julian are that 2,000 peri-operative consultants
will be required to serve the NHS in England and Wales. Since no
evenings or weekends are envisaged as being necessary, daytime
cover will restrict the numbers – hopefully on a 1:5 theatres ratio.
When asked who would provide anaesthesia for patients under the
supervision of a peri-operative medicine consultant, Julian explained
that this was a particularly tiresome question and the NHS should
have seen this development being necessary some time ago. Frankly
P2C2 do not see it as their problem and as long as someone (junior
consultant, trainee, nurse) provided anaesthesia, things would be fine
because a modernised service staffed with super specialists was what
is required.
‘There will always be teething problems, whenever
brave new solutions are developed!’
19 1
st
Moving
beyond audit:
using evidence
and data to
improve care
Courses for Clinicians
Course List
Date
Focused Intensive Care
Echocardiography (FICE) Course
11th October 2016
Course Details
Course Fee
FICE accreditation course for the Intensive Care
Society (ICS) and British Society of Echocardiography
(BSE)
£150
(including lunch and
refreshments)
£240
Earlybird price by 20th Sept or
£280 thereafter. (including Lunch
and Refreshments)
Training the Trainers
13th & 14th October 2016
A 2 day multi professional simulation course offering 10
CPD points for those interested in Simulation Education.
Resuscitation Update for
Consultants
27th September 2016 &
22 November 2016
A half day refresher course on managing cardiac arrest in
adults
£60
(including lunch and refreshments)
Cardiff Ultrasound Guided
Regional Anaesthesia with
Cadaveric Anatomy
Course Full
NEW date coming in Autumn!
A 2 day practical hands-on course that course enables
you to optimize and interpret the ultrasound machine’s
information and to apply it to real-world clinical
procedures.
£260
(including lunch and refreshments)
A 3 day practical course for all specialists who wish to
perform perioperative transoesophageal
echocardiography
£400
(including lunch and
refreshments)
Symposium Course Details
A 2 day lecture based course for all specialists who wish to
gain experty knowledge of
transoesophageal echocardiography.
£450
(including lunch and
refreshments)
Course Details
A 1 day course open to all health care workers who wish
to gain statistical experience.
£80 Earlybird price by 1st Oct or
£100 thereafter. (including Lunch
and Refreshments)
Course Details
A 2 day course covering all research competencies of
the 2010 high syllabus in research
£150 Earlybird price by 20th Nov or
£280 thereafter. (including Lunch
and Refreshments)
Cardiff Perioperative
Hands-on
Transoesophageal
Echocardiography (TOE)
Symposium
Research & Statistics Courses
Simple Statistics Excel & SPSS
Introduction to Research
Dates Available are:
5-7 July
20-22 September
15-17 November
12th &13th September 2016
21st
October
2016
15th and 16 December
Since its introduction, the National Emergency
Laparotomy Audit (NELA) has raised the profile
of this high-risk surgery and encouraged
measurement of outcome and process data,
so we ‘know how we’re doing’. Some hospitals
have used these data impressively to lead
improvement. We look at the winners of the
AAGBI NELA poster prize [1] to see how
application of improvement methodology has
helped the winning submissions to use their
NELA data to improve care.
All these hospitals have used their NELA data, together
with established quality improvement methods, to improve
care. Collecting data can be arduous, but to collect data
and not use it is wasted effort and lost opportunity. The data
are not the endpoint, but a launch pad to improvement.
Dr Martin Shao Foong Chong,
Dr Britta O’Carroll-Kuhn (abstract no. 157)
NELA implementation of peri-operative care
recommendations for patients undergoing emergency
laparotomy. An ongoing quality improvement project in a
district general hospital
The Kingston Hospital team showed that by improving the reliability of their
pathways they have also improved 30-day mortality for all patients, particularly
in those over 80. They used several PDSA cycles to guide an increase in
consultant anaesthetist and surgeon supervision, ITU admissions and time to
CT scan. They showed that improving their adherence to process measures
improved mortality (our most important outcome measure). They achieved
this impressive result by concentrating on each part of the process separately,
addressing and improving each problem in turn, using the data to guide them
in cycles of improvement.
Woolf et al. [2] use calculated examples to show that we would save far more lives
by improving healthcare delivery, rather than prioritising technical innovations.
This is especially true in complex pathways like emergency laparotomy; with
many different teams and elements involved, there are many points at which
patient care can break down and move away from what we know is the gold
standard. Of course, trying exciting new things is more appealing to most of us
than working on system fidelity and reliability: but how much more coverage
would be given to Dr Chong and Dr O’Carroll-Kühn’s 20% reduction in mortality
if it was achieved by using an innovative new piece of equipment or fluid regime?
‘Health, economic, and moral arguments make the case for spending less
on technological advances and more on improving systems for delivering
care’ Woolf, 2005
What is a PDSA cycle?
A Plan- Do- Study- Act cycle is the description given to an iterative cycle of
change used in the IHI ‘Model for Improvement’. The project team tests their
change idea by Planning it, implementing it (Do) and evaluate (Study) the
impact, then crucially alter their intervention based on what they have found
in real life testing (Act). They then undergo the same process again, maybe
multiple times, until they have refined their improvement idea to perfection. It is
a tried and tested method used to ensure change ideas work in the real world.
Congratulations again to the NELA poster prize winners for
their hard work and excellent results. Look out for the NELA
prize at next year’s WSM, highlighting the best examples of
application of NELA data to improve care.
Carolyn Johnston
Consultant anaesthetist,
St George's University Hospitals
NHS Foundation Trust
NELA QI Lead and member of
Health Foundation Q Initiative
To Register: click on this Link: https://form.jotformeu.com/cmhabc/CoursesAN
Website: For more information http:// www.bmc.wales
Anaesthesia News July 2016 • Issue 348
21 2
nd
NELA at Homerton Hospital: creating a new culture in
peri-operative care
Dr Flora Bailey,
Dr Tabitha Tanqueray (abstract no. 156)
Homerton Hospital used a range of teaching and engagement techniques
to encourage their colleagues to adopt the NELA guidelines. It’s easy
to say we should all change to adopt best practice, but why is making
this change so hard in real life? The National Institute for Health and
Care Excellence undertook a literature review [3] of which interventions
were most effective at changing a clinician’s behaviour. Unsurprisingly,
they found that passive interventions like disseminating guidelines were
usually unsuccessful (and yet the group email lives on!). More successful
strategies included active education initiatives, frequent patient specific
reminders, feedback of results, and local champions.
Teams should tailor their approach to their local environment. Multifaceted
interventions involving several strategies, like the Homerton’s strategy,
were found to be most successful in the review and also for Dr Bailey and
Dr Tanqeray. They elected NELA champions, created posters and reminder
notices for the in-theatre environment to prompt action at the right time
and gave regular feedback highlighting areas for improvement. Once they
had gained everyone’s ‘buy in’ by using a multifaceted approach, they
were able to improve documentation of risk scores, use of goal directed
therapy, ITU admissions and postoperative lactate measurement.
3
rd
Dr Susan Hayward, Dr Helen Bryant,
Dr Patrick Tapley, Dr Laura Tompsett,
Dr Jenny McLachlan (abstract no. 159)
3.
4.
'10. Graves: The Google Map of famous anaesthetists’ grave sites will
continue, though it was noted that it has been extremely difficult to find
locations.... It was suggested that the authors of obituaries are contacted
as they may have some insight.’
On my return home, I gave this problem some thought and decided that
it should actually be quite easy to find these graves, if one has the time
to devote to it. So, foolishly perhaps, I contacted the AAGBI archivist
Trish Willis, and asked her to send me the list of the graves she couldn’t
locate. Almost by return, a list of 19 names of the greats of anaesthesia
arrived in my inbox. The earliest death to chase was that of Humphrey
Davy who died in 1829 and the most recent was that of Thomas Cecil
Gray who died in 2008. This will be easy I thought. How wrong could I
be? This is the story of my expedition, almost entirely carried out from
my desk on my computer, with my good friends Google and Ancestry.
I have now completed my research and returned a full report to the
AAGBI Heritage Committee and this has been shared with the History
of Anaesthesia Society.
Photograph
of memorial
Boyle
Buxton
x
x
Davy
x
x
Memorial
x
Epstein
What is a run chart? A run chart is a line graph of your measure
(y axis), plotted over time (x axis), usually displayed with a horizontal
line displaying the median of the data. This format is helpful to spot
patterns or trends over time, and we can use simple run chart rules
to determine if changes are likely to random or not.
References
1.
2.
One of the great things about being a volunteer for the AAGBI’s Heritage
department is that you get to do things you never thought you would have to do.
So it was that at a volunteers meeting in July 2015, low down on the agenda, there
was an item titled ’graves‘. The minutes of that meeting report:
Grave
found
A simple solution to improving risk assessment
scoring for laparotomy cases using quality
improvement methodology
University Hospital Southampton’s poster focused on improving
pre-operative risk assessment. They got a marked improvement in
risk assessment from adding a P-POSSUM documentation box to
the booking form (Figure 1) and other interventions to encourage
completion. The poster has an impressive run chart showing their
incremental and sustained improvement (Figure 2). Note that the
run chart has a data point for every 10 patients. It might appear to
the research-trained mind that this sample size is too small. Etchells
et al. wrote a review in 2015 [4] describing small sample data
collection for quality improvement. They detail how onerous data
collection can cause quality improvement projects to fail, and that
small data samples are pragmatic and can allow rapid improvement.
They advocate several simple rules to keep your small data sample
representative (consecutive patients, strict data collection and
exclusion). By following this guidance and displaying data over time
on a run chart (time series), Dr Hayward and the team were able to
be confident their intervention was having the desired response, and
that the improvement was real and sustained.
AAGBI Graves of
the Greats Project
Abstracts of the AAGBI WSM London, 13–15 January 2016, London, UK. Anaesthesia 2016; 71 (suppl): 1–88.
Woolf SH, Johnson RE. The break-even point: when medical advances are less important than improving the fidelity with which they are delivered. Annals
of Family Medicine 2005; 3: 545–52.
Robertson R, Jochelson K. Interventions that change clinician behaviour: mapping the literature. National Institute of Clinical Excellence, 2006.
https://www.nice.org.uk/Media/Default/About/what-we-do/Into-practice/Support-for-service-improvement-and-audit/Kings-Fund-literature-review.pdf
Etchells E, Ho M, Shojania KG. Value of small sample sizes in rapid-cycle quality improvement projects. BMJ Quality & Safety 2016; 25: 202–6.
Featherstone
x
Goldman
x
x
Gray
x
x
Hewer
x
x
Hewitt
x
x
Hickman
x
Cremated
Death
certificate
Probate
x
x
x
x
x
Of the 19 names sent to me, I successfully located the graves of 11 and
I have photographs of nine of them. I have the name of the cemetery
for one but no further information. Four were cremated and one of these
has a memorial which was located. I have details of the death certificate
for ten of them (though I did not see the certificates themselves), and for
three I have details of the probate records.
For those of whom I have no details beyond death, I am most
disappointed that I was unable to get anywhere with Henry Edmund
Gaskin Boyle who died in 1941 in the Royal Cancer Hospital in Chelsea,
London. All his estate was left to his wife, valued at only £52 8s 9d!
The Proceedings of the History of Anaesthesia Society contain an
obituary for J Alfred Lee, written by Dr Tom Boulton in 1989, but this
obituary contains no mention of where his ashes are.
The conclusion is, if you write an obituary, please, please include
information about the grave – it would have made my job much easier,
but perhaps less fun.
The map is available online at https://goo.gl/Obj4Vo
With thanks to Drs Alistair McKenzie, Colin Birt and David Wilkinson.
Michael Ward
Retired Consultant Anaesthetist, NDA Oxford
x
x
The memorials found are shown here:
x
Dr Dudley Wilmot Buxton (1855–1931)
Heath Lane Cemetery, Boxmoor HP1 1JH Grave EB17c
Dr Henry Edmund Gaskin Boyle
Golders Green Crematorium, London
x
Sir Humphry Davy (1778–1829)
Plot 208 Cimitière Plainpalais, Rue des Rois, Geneva
Hans Georg Epstein (1909–2002)
Cremated: Ashes at: Section K1cr, 131 Wolvercote Cemetery, Oxford OX2 8EE
Victor Goldman (1903–1993)
Bushey Jewish Cemetery, London
Lee
x
Macintosh
x
x
Thomas Cecil Gray (1913–2008)
No: 420 Prinknash Abbey, Gloucestershire GL4 8EX
Magill
x
x
Christopher Langton Hewer (1896–1986)
Grave no: M2/77 East Finchley (aka St Marylebone) Cemetery
Minnitt
Cemetery
Mushin
Pask
x
Priestly
x
x
Robinson
x
x
Simpson
x
x
11
10
TOTAL
Sir William Frederic Hewitt (1857–1916)
G.674 Brighton and Preston Cemetery
x
Anaesthesia News July 2016 • Issue 348
x
Joseph Priestley (1733–1804)
Riverview Cemetery, Northumberland, Pennsylvania, USA
James Robinson (1813–1862)
Highgate Cemetery (West), London Borough of Camden
x
4
9
Sir James Young Simpson (1811–1870)
Warriston Cemetery, Edinburgh
3
John Snow
Brompton Cemetery, London
23 Too drugged
to drive?
5. If you prescribe a day case patient postoperative opiates to take
home, do you routinely advise them on driving? Yes or No
6. Do you feel well informed on the drug driving legislation, which
came in to force in March 2015? Yes or No or Unsure
There were 121 responses to the survey; 50% from consultants, 45%
trainees and the remainder made up by staff grades or associate
specialists.
Only 38% of respondents routinely provide verbal advice to their
patients on driving following day case anaesthesia or sedation, 29%
said that their hospital provided written advice regarding driving
on discharge, but 59% were unsure if this was the case and 12%
responded that their hospital provided no written information. Of
those surveyed, 74% provided no additional advice to day case
patients on driving when discharging them with postoperative
opiates.
Figure 1 – Surveyed anaesthetists recommendations on how long a
patient should abstain from driving following straightforward day case
anaesthesia or sedation.
On 2 March 2015 new drug driving legislation came into force in
England and Wales. The new offence is in addition to the existing
offence of driving while impaired through drugs (section 4 of the
Road Traffic Act 1988) and refers to driving, attempting to drive or
being in charge of a vehicle with a named drug in the body, in excess
of a specified limit [1]. A patient who is investigated for drug driving
is entitled to raise a statutory ‘medical defence’, providing the drug
was lawfully prescribed and taken in accordance with instructions.
It is the responsibility of the driver to ensure they do not drive if they
recognise they may be impaired, and the ‘medical defence’ will not
be extended to these circumstances. It is however the responsibility
of prescribers and suppliers of medication to provide advice on the
risks and side effects [1]. Testing takes the form of roadside saliva
screening tests followed by blood sampling.
Drug driving is surprisingly prevalent. The Transport Research
Laboratory collated data from road traffic accidents in 2010. Of
a total 1,037 driver fatalities in 2010, drug data was available for
231 cases. Of these, 20% were found to have ‘illegal’ substances
present and 31% ‘medicinal’ substances [2].
The specified limits (Tables 1 and 2) apply to 16 drugs in total, eight
associated with illegal drug use (but some of which may be used
in anaesthesia) and eight commonly associated with medicinal use
[3]. The Government has not been able to provide guidance on
the dosages that might equate to these blood levels. It is of note
that the threshold levels are set much lower for ‘illegal’ drugs such
as ketamine. Ketamine concentrations reach 2000–3000 mcg/L
during anaesthesia and it is unclear exactly how long it would take
24 levels to fall to the threshold of 20 mcg/L in any given patient. This
is in comparison to the ‘medicinal’ drug morphine for example,
where the threshold is set relatively high at 80 mcg/l. Notably,
patients at steady state receiving long-term morphine at a dose of
209 mg/day have average blood concentrations of only 66 mcg/L
[2]. The expert panel advising the Government recommended
that the threshold levels for many drugs be halved when found in
association with a blood alcohol level > 20 mg/100ml of blood [2].
This recommendation has not yet come into practice.
We conducted a survey to assess knowledge of the new drug driving
legislation and current practice in providing patient information on
driving following day case general anaesthesia and sedation.
A survey was compiled using SurveyMonkey® and emails sent out
to all five London schools of anaesthesia, with the request that the
survey was forwarded to all trainees and consultants. Responses
were collected from 26 November to 7 December 2015.
The questions:
1. What grade of anaesthetist are you?
2. Do you routinely provide verbal advice to your patients on
driving following day case sedation or general anaesthesia?
Yes or No
3. Does your hospital provide written advice on discharge to day
case patients regarding driving? Yes or No or Unsure
4. How long do you recommend a patient should abstain from
driving following straightforward day case sedation or general
anaesthesia? < 24 hrs, 24 hrs, 24–48 hrs, 48 hrs or > 48hrs
Anaesthesia News July 2016 • Issue 348
As shown in Figure 1, the vast majority of anaesthetists surveyed
(76%) felt that patients should abstain from driving for only 24
hours following day case anaesthesia or sedation and less than
8% recommended 48 hours or greater. When asked if they felt
well informed on the new drug driving legislation, only 4 out of 121
anaesthetists gave a positive response.
The majority of existing guidance suggests that patients should
abstain from driving for at least 24 hours. This is consistent with
our survey results. The BNF states that patients should be carefully
warned about the risk of driving and that for a short general
anaesthetic the risk extends to at least 24 hours [4]. The RCoA
advises that it is not usually safe to drive until at least 24 hours after
a general anaesthetic, and this should be extended to four days if
isoflurane has been used [5]. The AAGBI recommends 24 hours,
while additionally commenting on recovery from postoperative pain
[6]. However, all of this guidance was written prior to the introduction
of the new drug driving legislation.
The DVLA provides guidance on driving after surgery and suggests
that patients should consult with their doctor. The following issues
should be taken into consideration: recovery from surgery and
anaesthesia, pain, analgesia, as well as underlying conditions and
comorbidities [7]. In contrast to the existing advice from the RCoA,
AAGBI and BNF, a discussion with the DVLA medical advisor provided
the advice that patients undergoing short general anaesthesia for
day case surgery should be advised not to drive within 48 hours.
From our results it seems clear that there is an overwhelming lack
of awareness of the new drug driving legislation among those
anaesthetists surveyed. This is despite the recent publication
Anaesthesia News July 2016 • Issue 348
of articles such as New drug-driving laws and implications for
anaesthetists [8]. The authors discuss postoperative analgesia and
drug driving legislation, advocating a six-pronged approach to ensure
patients are well informed. It is of note that provision of information
on postoperative analgesia to patients in the pre-operative visit is a
standard to be met under Guidelines for the Provision of Anaesthetic
Services recommendations [9].
Our professional responsibility for the wellbeing of our patients
continues throughout the peri-operative period and must extend to
a safe discharge. If there are recognisable risks, then these must
be explicitly provided to the patient, who ultimately holds the legal
responsibility to not knowingly drive while impaired. All anaesthetic
departments should be providing patients with written information
in the pre-operative period. It may seem logical to combine the
information in a single patient information leaflet, ideally replicated
from a national standard.
Table 1 – Drug driving blood threshold levels for ‘illegal’ drugs [2]
‘Illegal’ drugs (‘accidental exposure’ – zero
tolerance approach)
Threshold limit in blood
Benzoylecgonine
50µg/L
Cocaine
10µg/L
Delta-9-tetrahydrocannibinol (cannabis)
2µg/L
Ketamine
20µg/L
Lysergic acid diethylamide
1µg/L
Methylamphetamine
10µg/L
MDMA
10µg/L
6-monoacetylmorphine (heroin)
5µg/L
Table 2 – Drug driving blood threshold levels for ‘medicinal’ drugs [2]
‘Medicinal’ drugs (risk based approach)
Threshold limit in blood
Amphetamine
250µg/L
Clonazepam
50µg/L
Diazepam
550µg/L
Flunitrazepam
300µg/L
Lorazepam
100µg/L
Methadone
500µg/L
Morphine
80µg/L
Oxazepam
300µg/L
25 A potential patient information leaflet on driving after anaesthesia
could include these points:
• Do not drive if impaired following general anaesthesia or when taking
postoperative opiates or benzodiazepines
• Do not drive if impaired by the surgical procedure. You should be
able to safely perform an emergency stop without discomfort
• If you are not impaired you may return to driving 48 hours after
general anaesthesia or sedation
• Factors such as alcohol consumption, age and taking new
medications (over the counter and prescribed) may increase the risks
of driving after surgery
EVELYN BAKER
MEDAL
How can we approach the potential problem of drug driving
after anaesthesia?
• A robust approach to inform and guide patients: information
leaflets (as above), strategically sited DVLA drug driving posters,
verbal advice on discharge, SMS/email reminders to patients postdischarge and television/radio publicity
• Prescription of individual analgesics postoperatively rather than
compound preparations, to facilitate early weaning off opiates.
Labels could also be attached to opiates/benzodiazepines to warn
patients of the risks
• Additionally we need to consider whether we should be providing
patients on discharge with details of drugs administered during
anaesthesia, such that in the event of testing positive on a drug
driving test they could provide evidence
• It would also be important to educate trainee anaesthetists on the
issues, perhaps by targeting digital media avenues such as a short
e-learning module or podcast
AN AWARD FOR OUTSTANDING
CLINICAL COMPETENCE
Michelle Le Cheminant
Clinical fellow
Manish Raval
Consultant anaesthetist
David Celaschi
Consultant anaesthetist
Moorfields Eye Hospital
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
26 Guidance for healthcare professionals on drug driving. Department for Transport. July 2014. https://
www.gov.uk/government/uploads/system/uploads/attachment_data/file/325275/healthcare-profsdrug-driving.pdf
https://www.gov.uk/government/collections/drug-driving#table-of-drugs-and-limits
Driving under the influence of drugs. Report from the expert panel on drug driving. March 2013.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/167971/drug-drivingexpert-panel-report.pdf
British National Formulary. http://www.bnf.org
Royal College of Anaesthetists ‘frequently asked questions’. http://www.rcoa.ac.uk/patients-andrelatives/common-concerns-and-faqs#How%20long%20do
Day Case and Short Stay Surgery. Association of Anaesthetists of Great Britain and Ireland. May 2011.
https://www.aagbi.org/sites/default/files/Day%20Case%20for%20web.pdf
DVLA. At a glance guide to the current medical standards of fitness to Drive. Updated August 2015.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/457961/aagv1.pdf
Grimes L, Clayton S, Grimsdell R and Levy N. New drug-driving laws and implications for anaesthetists.
Bulletin September 2015;93:45.
Guidelines of the Provision of Anaesthetic Services. Anaesthetic Services for pre-operative assessment
and preparation 2014. http://www.rcoa.ac.uk/system/files/GPAS-2014-02-PREOP_2.pdf
Particles
Last year the award was won by Drs John Leigh
(Bristol), Virin Sidhu (London) and Patricia Weir
(Bristol). Details of previous award winners and
further information can be found on the website
http://www.aagbi.org/about-us/awards/evelynbaker-medal
Nominations are now invited for the award, which
will be presented at WSM London in January
2017. Members of the AAGBI can nominate any
practising anaesthetist who is also a member of
the Association. Nominees should normally still
be in clinical practice. The award is unlikely to
be given to someone in their first ten years as
a consultant or SAS doctor, and the nominee
should not be in possession of a national award.
Nominations should include an indication that
the nominee has broad support within their
department.
Neurodevelopmental outcome at 2 years of age
after general anaesthesia and awake-regional
anaesthesia in infancy (GAS): an international,
multicentre, randomised controlled trial
Lancet 2016; 387: 239–50.
Background
For some time there has been concern that anaesthesia in infancy can have long
term effects on brain development. Animal studies have indicated that exposure to
general anaesthesia (GA) in infancy causes changes in brain development [1] and is
associated with long term cognitive and behavioural change [2–4]. In humans, cohort
studies and meta-analyses have concluded there is an association between anaesthetic
exposure in early life and adverse neurodevelopmental outcome [5,6]. These studies
have been unable to establish direct causation due to the nature of their methodology.
This is the first randomised controlled trial looking at whether GA in infancy affects
neurodevelopmental outcome. It examines neurodevelopmental outcome in infants
undergoing inguinal herniorrhaphy, either using an awake regional technique (RA) or
under sevoflurane GA. Inguinal herniorrhaphy was chosen, as two well established
anaesthetic techniques are employed for this age group. The primary aim of the trial was
to assess neurodevelopmental outcome at age 5. This paper reports on a secondary
outcome: neurodevelopmental outcome at age 2.
Methodology
This was an observer blind, multicentred, randomised controlled equivalence trial.
The trial included infants born between 26 weeks and 60 weeks, post menstrual
age, who were scheduled to undergo unilateral or bilateral inguinal herniorrhaphy.
They underwent stratified randomisation to either GA or RA. The psychologists and
paediatricians assessing neurodevelopment were unaware of group allocation.
The study protocol specified that no opiates, benzodiazepines or nitrous oxide were
administered in either group. If the RA was ineffective then conversion to GA occurred.
For postoperative analgesia, a caudal or ilioinguinal block was permitted in both groups.
Oral or intravenous paracetamol could also be given. Neurodevelopmental outcome
was subsequently assessed at age 2 using the Bayley-III scale of infant and toddler
development [7].
Results
The study randomised 363 infants to the RA and 359 to the GA group. Outcome data
were available for 238 children in the RA and 294 in the GA group. Mean duration of GA
was 54 minutes and 74 children in the RA group converted to GA. Bayley-III scores were
equivalent in the two study groups.
Conclusion
This study found no evidence that a GA in infancy of less than one hour increases the
risk of adverse neurodevelopmental outcome at age 2 when compared with RA. Though
limited in certain respects, the randomised controlled design of this study ensured that
the evidence generated was robust and provided useful additions to existing research.
The primary outcome of this trial will be reported in 2018 and reassessment of these
children must be awaited before definitive conclusions can be made. This trial looks
at the effect of a relatively short GA and further research will be needed to quantify the
longer term effects of multiple and or prolonged GA on infants.
Roopa McCrossan
ST6 Anaesthesia, Health Education North East
References
1.
2.
3.
The nomination, accompanied by a
citation of up to 1000 words, should
be sent to the Honorary Secretary at
[email protected] by 17:00
on Friday 15 July 2016.
Anaesthesia News July 2016 • Issue 348
A randomised controlled trial of intrathecal
blockade versus peripheral nerve blockade
for day-case knee arthroscopy
Anaesthesia 2016; 71: 280–4
Davidson AJ, Disma N, de Graaff JC, et al
The Evelyn Baker award was instigated by
Dr Margaret Branthwaite in 1998, dedicated
to the memory of one of her former patients
at the Royal Brompton Hospital. The award
is made for outstanding clinical competence,
recognising the ‘unsung heroes’ of clinical
anaesthesia and related practice. The defining
characteristics of clinical competence are
deemed to be technical proficiency, consistently
reliable clinical judgement and wisdom and skill
in communicating with patients, their relatives
and colleagues. The ability to train and enthuse
trainee colleagues is seen as an integral part of
communication skill, extending beyond formal
teaching of academic presentation.
Ambrosoli AL, Chiaranda M, Fedele LL, Gemma M, Cedrati V, Cappelleri G
4.
5.
6.
7.
Jevtovic-Todorovic V, Absalom AR, Blomgren K, et al. Anaesthetic neurotoxicity and
neuroplasticity: an expert group report and statement based on the BJA Salzburg Seminar.
British Journal of Anaesthesia 2013; 111: 143–51.
Jevtovic-Todorovic V, Hartman RE, Izumi Y, et al. Early exposure to common anesthetic agents
causes widespread neurodegeneration in the developing rat brain and persistent learning
deficits. Journal of Neuroscience 2003; 23: 876–82.
Paule MG, Li M, Allen RR, et al. Ketamine anesthesia during the first week of life can cause
long-lasting cognitive deficits in rhesus monkeys. Neurotoxicology and Teratology 2011; 33:
220–30.
Raper J, Alvarado MC, Murphy KL, Baxter MG. Multiple anesthetic exposure in infant monkeys
alters emotional reactivity to an acute stressor. Anesthesiology 2015; 123: 1084–92.
DiMaggio C, Sun LS, Ing C, Li G. Pediatric anesthesia and neurodevelopmental impairments:
a Bayesian meta-analysis. Journal of Neurosurgical Anesthesiology 2012; 24: 376–81.
Wang X, Xu Z, Miao CH. Current clinical evidence on the effect of general anesthesia on
neurodevelopment in children: an updated systematic review with meta-regression. PLoS One
2014; 9: e85760
Bayley N. Bayley scales of infant and toddler development. 3rd ed. San Antonio: Harcourt
Assessment Inc, 2006.
Anaesthesia News July 2016 • Issue 348
Introduction
One hundred patients scheduled for day-case knee arthroscopy were allocated
to two groups. Group 1 received unilateral spinal anaesthesia with 40 mg
hyperbaric prilocaine and Group 2 received ultrasound-guided femoral-sciatic
nerve blockade with 25 ml mepivicaine 2%.
The aim of this study was to compare the low dose of intrathecal to peripheral
nerve block. The areas of comparison included simplicity, shorter duration of
onset, predictability of duration and side effects. This would be beneficial in
day-case patients enabling early discharge with minimum anaesthetic and
analgesic requirements.
Methodology
A randomised controlled trial was carried out in Italy between January and April
2015. Age range of patients was 18 to 70 with ASA 1–2 physical status. All
patients received a 20G cannula with 500 ml normal saline and 0.05 mg/kg of
midazolam and standard monitoring.
Group 1 were placed in a lateral position and administered 2 ml of 2% prilocaine
given intrathecally using a 25G Sprotte needle. In Group 2 an ultrasoundguided 80 mm 22G needle was used in-plane to inject 15 ml of mepivacaine
2% around the femoral nerve with a further 10 ml under the sciatic perineural
sheath.
The time taken for neuroaxial and peripheral nerve block and their onset was
recorded. Haemodynamic variables were recorded every 5 min in theatre and
every 30 min till discharge from hospital. Intra-operative pain was treated with
100 mcg of fentanyl, after which general anaesthesia was the only option.
Postoperatively, patients received paracetamol and 30 mg intravenous
kertorolac. A blinded investigator recorded the times of voiding, walking, blood
pressure and heart rate, and discharge of patients with maximum pain score
of 4 on the numeric rating scale. Participants were then contacted after 24h
and one week post discharge. Chi- squared and Fishers exact test were used
for statistics.
Results
The median time for intrathecal anaesthesia was 3 min while for peripheral
nerve block this was 5.5min. Average onset time for the blocks was 6 and
6.5 min, respectively. Two patients in Group 1 and eight patients in Group 2
required fentanyl for breakthrough pain. Median time to miturate was 225 min
(Group 1) and 220 min (Group 2), while the time taken to walk was 285 min
and 328 min, respectively. Group 1 patients went home quicker. Intraoperative
hypotension was treated in six participants all of whom were in Group 1.
Discussion
Intrathecal group participants were associated with quicker onset, quicker
recovery and early discharge. Hyperbaric prilocaine as compared to
bupivacaine has been used for ambulatory surgery from 20 mg (with fentanyl)
to 60 mg, with better results and fewer side effects. Intrathecal blockade is
more reliable. One limitation of the study was the inability to blind the assessor
to the outcome which could bring about a bias.
Conclusion
This paper is well-written and designed although the groups studied are small.
The operators were experienced which allowed more accuracy of blocks. The
study was done in ASA 1 and 2 patients who tend to have fewer complications
overall as compared to patients with multiple comorbidities; therefore this study
does not achieve the real benefit of early discharge after regional or nerve block.
Tariq Azad
ST3 Anaesthetics, James Cook University Hospital, MIddlesbrough
References
1.
Montes FR, Zarate E, Grueso R, et al. Comparison of spinal anesthesia
with combined sciatic-femoral nerve block for outpatient knee arthroscopy.
Journal of Clinical Anesthesia 2008; 20: 415–20.
2.
Williams BA, Kentor ML, Vogt MT, et al. Femoral-sciatic nerve blocks for
complex outpatient knee surgery are associated with less postoperative
pain before same-day discharge: a review of 1,200 consecutive cases from
the period 1996-1999. Anesthesiology 2003; 98: 1206–13.
3.
Cappelleri G, Casati A, Fanelli G, et al. Unilateral spinal anaesthesia or
combined sciatic-femoral nerve block for day-case knee arthroscopy. A
prospective randomized comparison. Minerva Anestesiologica 2000; 66:
131–6.
27 The Wylie Medal 2015
Peri-operative medicine is a subspecialty, with doctors able to
effectively identify and meet the complex medical needs of patients
at particular risk from the adverse effects of surgery [3]. The critical
involvement anaesthetists have with patients in the peri-operative
period readily lends itself to the title ‘peri-operative physician,’
which has been one of the over-arching arguments for change.
Another argument for adopting this title is the scope it brings for
enhanced recovery; a multidisciplinary approach to peri-operative
care with the aim of earlier hospital discharge. Enhanced recovery
has gained attention recently for its ability to achieve impressive
reductions in hospital stay and surgical morbidity; it is hoped perioperative physicians could play a major role that is currently unmet
by anaesthetists [4,5].
However, it is important to remember it is not just a change of
name, but also a change of role, and careful consideration of
the practicalities involved is imperative. While the role of the
anaesthetist in theatre is defined, the would-be role both pre- and
postoperatively are more contentious. Webster [6] highlighted the
28 ®
19th Anaesthesia, Critical Care
and Pain Forum
Da Balaia, The Algarve
26-28 September 2016
It is clear that adopting the new roles associated with peri-operative
physicians could have benefits for patients. However, it is important
to appreciate the unique skill set anaesthetists have, and that
assigning them to medical jobs could leave them with less time to
anaesthetise patients; a skill no other speciality could supplement.
Perhaps one solution could be making peri-operative medicine
a subspecialty of anaesthetics, in the same way that some
anaesthetists specialise in pre-operative assessment or acute pain.
This would mean not all anaesthetists are spending less time in the
operating theatre, while still achieving the expected benefits. This
is certainly an avenue that demands further exploration.
Anaesthetist
or peri-operative
physician?
According to the Royal College of Anaesthetists, the anaesthetist’s
major role lies in ‘providing anaesthesia during surgery,’ while
acknowledging ‘this role is ever widening’, and ‘their skills are used
in all aspects of patient care’ [1]. It is certainly true that anaesthetists
are not only found in the operating theatre. The diversity of their
experience, skills and training takes them from ICU to chronic
pain management clinics, with only 37% of their time spent in
theatre [2]. With their role extending far beyond that of just putting
patients to sleep, it has been argued the job title is outdated, not
accurately encompassing the extensive range of responsibilities
an anaesthetist adopts daily. ‘Peri-operative physician’ has been
proposed as an alternative job title, more accurately defining the
remits of an anaesthetist’s work. Is formally adopting this new role,
and accompanying name change, the next step for anaesthetics?
And would it improve patient outcomes: arguably the main driver
for any change in healthcare?
much evidence to show that the timely recognition and treatment
of complications has a considerable impact on morbidity and
mortality. Indeed, postoperative complications are a more important
determinant of long-term survival than comorbidities or intraoperative adverse events [3,11]. Similarly, pre-operative care has
a significant impact on survival, as decreasing the stress response
to surgery and trauma is the key factor in improving outcomes, as
well as the total costs of patient care [12,13].
doctorsupdates
The Association of Anaesthetists of Great Britain & Ireland:
analogy of a patient with uncontrolled diabetes or hypertension,
seen by the anaesthetist on a routine pre-operative visit. As currently
defined, the anaesthetist makes a referral to the appropriate
medical speciality for investigations and treatment. Should this
new title and associated role be adopted, these tasks might
instead fall to the peri-operative physician. Similarly, anaesthetists
are responsible for the management of common postoperative
symptoms, including pain, nausea and dizziness. Typically care
is then taken over by other hospital specialities or the primary
healthcare system. Adopting the role of a peri-operative physician
would make it the anaesthetists’ job to routinely and regularly
examine patients in the postoperative period, with the subsequent
escalation and provision of further investigations and treatment.
From my limited time as an undergraduate in anaesthetics, I can
anticipate a significant change in the system would be needed
to accommodate this extra workload. Furthermore, a greater
exposure to general medicine during training would be required.
The question is: what are the benefits?
Patients’ experiences and outcomes are the central driving force
for any changes made within the NHS. Of the seven key principles
that underpin the NHS’s core values, number three focuses on the
provision of high-quality care that is safe, effective and focused
on patient experience [7]. The argument that adopting the roles
of the peri-operative physician has the ability improve patient
outcomes is therefore of upmost importance [3]. With the number
of operations (‘procedures and interventions’ as defined by
Hospital Episode statistics, excluding diagnostic testing) close to
10 million per year in the UK [8], even small changes in patient
care can have a significant effect on patient outcomes [9]. For
instance, the implementation of the surgical safety checklist saw
death rates fall by 40% over the course of a year, and the rate of
complications by almost a third [10]. It is thought that continuum
of the same physician peri-operatively could also reduce morbidity
and mortality associated with surgery, as, although successful
surgery is necessary for good postoperative outcomes, there is
Anaesthesia News July 2016 • Issue 348
Whether anaesthetists as they currently stand should change both
their title and role to peri-operative physicians is multifaceted,
and not a decision to be taken lightly. Of the anaesthetists I have
shadowed thus far, I am certain most would argue that, to some
extent, they are already finding medical problems in their patients
and treating them. They would also argue that their time is limited,
and adopting any new role would require a system reorganisation.
Whether or not the change from anaesthetists to peri-operative
physician would benefit patients is the fundamental question.
There is hope that peri-operative physicians would reduce the
risk of mortality and morbidity associated with surgery, as well as
play a crucial role in enhanced recovery surgery; currently unmet
by anaesthetists. Far above any other reasoning, the potential for
improvements in patient outcomes should be the driver for any
change.
Charlotte Dunn
Fourth Year Medical Student, Cardiff University
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Royal College of Anaesthetists. What do Anaesthetists do? http://www.rcoa.
ac.uk/considering-career-anaesthesia/what-do-anaesthetists-do (accessed
21/12/2015).
Ingram S. National snapshot of anaesthetic activity. Royal College of
Anaesthetists Bulletin 2000; 1: 9.
Grocott MP, Pearse RM. Perioperative medicine: the future of anaesthesia?
British Journal of Anaesthesia 2012; 108: 723–6.
Kitching AJ, O’Neill SS. Fast-track surgery and anaesthesia. Continuing
Education in Anaesthesia, Critical Care and Pain 2009; 2: 39–43.
White PF, Kehlet H, Neal JM, Schricker T, Carr DB, Carli F. The role of
the anesthesiologist in fast-track surgery: from multimodal analgesia to
perioperative medical care. Anesthesia & Analgesia 2007; 104: 1380–96.
Webster NR. The anaesthetist as peri-operative physician. Anaesthesia 2000;
55: 839–40.
NHS Choices. Principles and values that guide the NHS. http://www.nhs.
uk/NHSEngland/thenhs/about/Pages/nhscoreprinciples.aspx (accessed
23/12/2015).
NHS Confederation. Key statistics on the NHS, 2015. http://www.nhsconfed.org/
resources/key-statistics-on-the-nhs (accessed 24/12/2015).
Halpern D. Inside the Nudge Unit: How small changes can make a big
difference. London: Ebury Publishing, 2015.
Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce
morbidity and mortality in a global population. New England Journal of
Medicine 2009; 360: 491–9.
Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ.
Determinants of long-term survival after major surgery and the adverse effect of
postoperative complications. Annals of Surgery 2005; 242: 326–41.
Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. The
American Journal of Surgery 2002; 183: 630–41.
Zambouri, A. Preoperative evaluation and preparation for anesthesia and
surgery. Hippokratia Medical Journal 2007; 11: 13–21.
www.doctorsupdates.com
education in a perfect location ®
7th Critical Care London Meeting
Tuesday 13th & Wednesday 14th September 2016
Brunei Gallery, School of Oriental & African Studies, London
Conference Chairmen and Scientific Committee:
Maurizio Cecconi, Andrew Rhodes & Jonathan Ball, St George’s Hospital
A national event to update doctors and other
healthcare professionals working in Intensive Care
on the latest knowledge and thinking
Royal College
of Anaesthetists
CPD Approval Pending
Expert faculty including:
Luciano Gattinoni, Milan
Jacques Duranteau, Paris
Anthony Gordon, Imperial College
Andrew Shennon, King’s College London
Richard Beale, St Thomas’ Hospital
Mark Peters, Great Ormond Street
.... and more
Pre-congress workshops will be held on
the afternoon of Monday 12th September
Limited places available - Early booking recommended
For further information or to request a copy of the full programme,
please contact [email protected]
Registration Fees:
Professor/Consultant
Non-Consultant Grades
Nurse/Physiotherapist/
Pharmacist/Scientist
Early Bird (until 31 July) Standard (from 1 August)
One Day
Both Days
One Day
Both Days
£150
£300
£175
£350
£100
£200
£125
£250
£65
£125
£75
£150
How To Register:
Online: www.hartleytaylor.co.uk
Email: [email protected]
Tel: 01565 621967
Anaesthesia News July 2016 • Issue 348
29 New Membership
Services Committee
In February, the AAGBI Board of Directors decided to establish a new
Membership Services Committee, which will be launched in September.
It will be chaired by the Honorary Membership Secretary, Dr Nancy Redfern.
As a membership organisation, the AAGBI provides a broad
range of services to our 11,000 plus members, from education
and publications to support for individual wellbeing. The new
committee will have oversight of the whole range of services
and of member retention and recruitment generally. Its role will
encompass member engagement; improving communications
with all AAGBI members, for instance through the bi-annual
member surveys and through Linkmen networks, as well as
finding ways to reach out to and recruit those who are not yet
members. Over time, the committee will also evaluate options
for new, and improvements to, existing services for members
It is proposed that an early task for the committee will be to
develop a strategy to engage with SAS and non consultant non
trainee doctors and to grow the number of active members in
this grade. Current membership figures show that there are
many SAS doctors who are not AAGBI members. Previous
membership recruitment campaigns have been only partially
successful in bringing in new SAS members.
The aim of the exhibition is to showcase the talents of all
anaesthetists and their families and help raise funds for the Lifeboxes
for Rio campaign. It would greatly assist us if you register your work
in advance as it will enable us to plan the exhibition and provide a
catalogue of contributors for visitors’ use during the exhibition.
In recent years the exhibition has been opened out to
include all manner of art and craft other than the mainstay painting
and photography. We have had jewellery, needlework, beading,
sculpture, pots - there seems to be no end to the creativity of
anaesthetists and their families!
Please come along and support the Art Exhibition in Birmingham in
September. You can do this in so many ways. You can:
•
•
•
•
•
Take a guess
I was in the operating theatre with an anaesthetised patient. My
registrar walked in, saw the monitor and asked me: ‘Why isn’t there
an ECG on the monitor?’ (Fig. 1). I said there wasn’t an ECG because
the patient didn’t have a heart. He looked puzzled. Yes. The patient
didn’t have his native heart, but instead a temporary Total Artificial
Heart (TAH-t, SynCardia Systems Inc, Tucson, AZ). The TAH-t is
made of plastic or polyurethane derivative and is approved for use
to bridge to heart transplant in eligible patients at risk of imminent
death due to biventricular heart failure [1]. The SynCardiaTM TAH-t is
the only total artificial heart that is commercially available in the USA,
EU and Canada for use as a bridge to heart transplantation.
Further updates about the appointment of members of the new
committee will follow in due course.
Artistic anaesthetists are encouraged
to submit their artwork to this year’s
Art Exhibition.
AT ANNUAL CONGRESS,
BIRMINGHAM 14-16 SEPT 2016
Why isn’t there an ECG on the monitor?
Contribute by exhibiting some of your art or craft
Donate for sale any you can bear to part with
Buy a stunning work of art created by a colleague for a fraction
of the market cost
Buy beautiful greetings cards
Just simply visit and enjoy the talents of your colleagues
For further information and a submission form,
please visit www.annualcongress.org or contact
[email protected].
Figure: 1 Monitoring during anaesthesia without ECG
Once implanted, the TAH-t replaces the patient’s native left and right
ventricle, the tricuspid, aortic, mitral and pulmonary valves (Fig. 2).
The two artificial ventricles are connected to the patient’s native atria,
aorta and pulmonary artery. The TAH-t functions with two separate
pneumatically driven pulsatile pumps. These assume the role of the
native ventricles and are powered by an external driver. The driver
delivers air to the diaphragm, causing it to rise to the top of the
ventricle and thereby ejecting the total volume. Device ejection and
forward flow of blood is preload-dependent and increases with atrial
pressure. With adequate preload, cardiac outputs of up to 9.5 l/min
can be generated. Unlike for ventricular assist devices, there is no
need to place ECG leads and monitor the ECG, because patients
with TAH-ts no longer have native heart tissue to conduct an ECG
tracing. The TAH-t heart rate is generally
set from 90 beats /min to 130 beats/
min to achieve an appropriate cardiac
output based on the patient’s overall
condition, age, size and activity level.
The target stroke volume is monitored
continuously. TAH-t parameters are
usually managed and adjusted by
a multidisciplinary team, including
artificial heart specialists, transplant
physicians, surgeons and intensivists.
The Freedom® portable driver design
permits patient discharge from hospital
while awaiting transplantation (Fig.
3) after appropriate training in the
Figure 2: Total artificial heart
management of the device.
(Courtesy of Syncardia.com)
Anaesthesia News July 2016 • Issue 348
Figure 3: Freedom® portable device driver design (Courtesy of Syncardia.com)
When managing a patient with a TAH-t, the provider should remember
that inotropic agents would not change the haemodynamic [2] and
insertion of pulmonary artery catheter in contraindicated. Defibrillation
and CPR will not be effective and patients with a TAH-t should not
be subjected to a MRI scan. It is strange to induce and maintain
anaesthesia for any patient without an ECG monitor, but one gets
used to it. In fact, it’s one less monitor to worry about when you look
after these patients either in the theatre or in the intensive care unit!
Acknowledgments
With thanks to André R Simon, director of heart and lung
transplantation and ventricular assist devices, and his team and the
department of anaesthesia and critical care at Harefield Hospital for
their involvement in the total artificial heart programme. The author
declares no conflicts of interest.
Lakshmi Kuppurao
Consultant cardiothoracic anaesthetist, Harefield Hospital
References
1. Copeland JG, Smith RG, Arabia FA, et al. CardioWest Total Artificial Heart
Investigators. Cardiac replacement with a total artificial heart as a bridge to
transplantation. New England Journal of Medicine 2004; 351: 859–67.
2. Shah KB, Tang DG, Cooke RH, et al. Implantable mechanical circulatory
support: demystifying patients with ventricular assist devices and artificial
hearts. Clinical Cardiology 2011; 34: 147–52.
31 Dear Editor
Dear Editor
For the
latest news
and event
information
follow
@AAGBI
on Twitter
First, I must congratulate you on your excellent April 2016
issue of Anaesthesia News. I particularly enjoyed the article
‘Blogadder returns’ but I must admit to suffering a bout of quite
severe grammatical pain at Blogadder’s evident inability to
differentiate between an acronym and an initialism. The former is
an abbreviation formed from the initial letters of other words and
pronounced as a word; the latter is an abbreviation consisting of
initial letters pronounced separately. NAP and AAGA therefore
count as acronyms, as does – at a push – AAGBI, although it is
usually spoken as an initialism. However, contrary to Blogadder’s
assertions, CPD, LGBTI, LTFT and GMC are, without doubt,
initialisms.
Such subtle grammatical differences may mean little to many but,
be assured, there are those of us whose grammatical instincts are
so finely tuned that an outwardly minor error such as this can be
the cause of much suffering. Please ask Blogadder to bear this in
mind when he/she next puts pen to paper.
Yours pedantically
Grammar Tyrant
Dear Gramza
Thank you for your comments. I am sorry that your symptoms have
not yet responded to your coarse of CBT. You are quite correct in
your analysis of the terminology but make a not uncommon error,
‘CPD, LGBTI, LTFT and GMC are without doubt initialisms’.
In fact these initialisms can regularly be heard in these parts being
pronounced as words, i.e as acronyms. For example, late in the
afternoon to a barman, ‘Hey Jimmy, gie’z a CPD LGBTIs fur the
LTFTs ‘n a packet of crisps!’
A creative method for aiding gas induction in children
Here is a seldom used but simple and effective way of entertaining
a child during delivery of a gaseous induction. This technique
requires the use of an Ayre's T-piece and a bottle of bubbles;
equipment that is readily and easily available. In our experience,
it can be used in most children over 3 years of age and can even
be an effective distraction in older children. The child breathes
as is routine via the facemask of an Ayre's T-piece, which the
anaesthetist or the child holds in place. Meanwhile, the outlet
of the reservoir bag is held in place while the paediatric nurse
or parent repeatedly refills the bubble wand with detergent. The
child is therefore responsible for the formation of the bubbles,
which provides a fantastic incentive for the child to breathe
faster and take deeper breaths, thereby speeding up the onset
of anaesthesia. Another advantage of this technique is that the
bubbles are aimed towards the foot of the bed avoiding the
anaesthetic team being blinded by bubbles at a crucial stage of
the anaesthetic.
GMC is a widely used swear word on which I am injuncted not to
comment further.
I shall of course try to be more pedantic in future.
Blogadder
Mervin Loi1 Caroline Price2 and Sallyanne Wheatley3
Dear Editor
We congratulate Dr Choo and Dr
Tamhane on their cheap and simple
loss of resistance simulator [1].
However, they are far from the first
authors to utilise greengrocery items
for this purpose, although they are
the first team of which we are aware
that used root vegetables rather
than fruit [2, 3]. With colleagues, we
built on the work of Cloote et al. in
a blinded trial comparing the realism
of loss of resistance between a
banana, an orange, a kiwi fruit and
a honeydew melon [4]. The banana
was discovered to be statistically
significantly more realistic than the
other fruits tested.
Printing error on a laryngeal mask
1.
2.
3.
32 Jain A, Chandra R. Untitled letter. Anaesthesia News 2016; 343: 29.
Pearson J, Maund A, Meek T. Epidural failure. Anaesthesia News 2015; 339: 21.
3M™ Tegaderm™ Transparent Film Dressing with Border. http://www.3m.com/3M/en_US/company-us/all-3m-products/~/3M-Tegaderm-Transparent-Film-Dressingwith-Border?N=5002385+8707795+8707798+8710820+8711017+8711097+8711738+8717839+3293321974&rt=rud (accessed 22/3/2016).
Anaesthesia News July 2016 • Issue 348
While teaching a novice anaesthetist about laryngeal mask (LM) usage recently, I discovered
a printing error on a size 2 LM.
It would be interesting if Dr Choo,
or others, could perform a head-tohead comparison of the banana and
the potato, in order to discover which
of these techniques bears fruit and
which should be buried.
Roy Williamson
Consultant Anaesthetist, Royal
Alexandra Hospital, Paisley
Diana Raj
Consultant Anaesthetist, Queen
Elizabeth University Hospital, Glasgow
References
1.
2.
Drs Jain and Chandra describe the use of a plastic bag component of epidural packaging to wrap and protect the epidural connector
assembly [1], as a cheaper and greener alternative to the TegadermTM proposed in our earlier letter [2]. Readers ought to take note that
the Tegaderm dressing we recommended is a CE marked device and its use in the manner we suggested is within the product specification
[3], whereas neither is true of the plastic bag in the authors’ suggestion. Using a non CE marked device potentially places liability on the
user; whether in this instance this is offset by the saving in cost of a single Tegaderm is for individuals and units to decide. At the certain risk
of appearing pedantic, an editor’s footnote to a letter on the opposite page to Jain and Chandra’s reminds us: ‘The AAGBI does not support
the use of non-CE marked equipment’.
Tim Meek
Chair, AAGBI Safety Committee
References
The Editor, Anaesthesia News at [email protected]
Please see instructions for authors on the AAGBI website
Dear Editor
Paediatric Intensive Care Unit, Bristol Royal Hospital for Children,
2
Anaesthetic Department, Gloucestershire Royal Hospital,
3
Anaesthetic Department, John Radcliffe Hospital, Oxford
Editor’s note:
This method is used in our hospital, but thoroughly disapproved
of by our infection control team. The bubble bottles are now
strategically placed when they visit...
SEND YOUR LETTERS TO:
Dear Editor
1
*written permission was obtained for the photograph
your Letters
3.
4.
Choo Y, Tamhane P. A novel way to
practice loss of resistance technique!
Anaesthesia News 2016; 345: 37.
Cloote AH, Parke TJ, Kinsella SM.
An analysis of three different loss
of resistance techniques using the
‘greengrocer’s’ epidural simulator.
International Journal of Obstetric
Anesthesia 1995; 4: 182–3.
Leighton BL. A greengrocer’s model
of the epidural space. Anesthesiology
1989; 70: 368–70.
Raj D, Williamson RM, Young D, Russell
D. A simple epidural simulator: A
blinded study assessing the 'feel' of loss
of resistance in four fruits. European
Journal of Anaesthesiology 2013; 30:
405–8.
I was using the instructions on the LM and LM packaging to demonstrate that some
companies print the size of LM and the patient weight range for which it is appropriate.
I noticed that the wrong weight range (10–30 kg) was printed on the size 2 LM, but the correct
weight range was printed on the package.
I contacted the company with regard to the error and following their investigation they
advised me that they use a printing plate to print on the LM. They found two printing plates
at the manufacturing site and one had the wrong patient weight range information (10–30
kg); this had been used in error. The company submitted a report to the MHRA and sent
letters to hospitals across the UK and Republic of Ireland about the printing error. They also
advised me that they have now recalled and collected other similar LMs with the same errors
and returned them to the manufacturer.
Mahadevappa Lohit
ST6 Anaesthetics
Mary Mushambi
Consultant Anaesthetist
Leicester Royal Infirmary
Anaesthesia News July 2016 • Issue 348
33 NIAA
National Institute of Academic
Anaesthesia
TRAVEL GRANTS/IRC FUNDING
The International Relations Committee (IRC)
offers travel grants to anaesthetists who
are seeking funding to work, or to deliver
educational training courses or conferences,
in low and middle-income countries.
Please note that grants will not normally be considered for
attendance at congresses or meetings of learned societies.
Exceptionally, they may be granted for extension of travel
in association with such a post or meeting. Applicants
should indicate their level of experience and expected
benefits to be gained from their visits, over and above
the educational value to the applicants themselves.
For further information and an application form
please visit our website:
http://www.aagbi.org/international/irc-fundingtravel-grants
or email [email protected]
or telephone 020 7631 1650 (option 3)
5 October 2016
Save
the date
13/05/2016 10:12
Obstetric
Anaesthesia
Update
New venue for 2016
Royal College of Physicians, London
TOPICS INCLUDE:
THE ROLE OF ULTRASOUND ON THE LABOUR WARD
AND HUMAN FACTORS IN OBSTERIC ANAESTHESIA
6 October 2016
Applications are invited for the position of Academic
Training Coordinator for the NIAA.
This is a 3 year fixed term appointment to promote and
develop training in research for trainees in anaesthesia,
perioperative medicine and pain (APOMP).
The post-holder will oversee development of the RCoA
curriculum for training in research, alongside the RCoA
Training Committee and the NIAA Board. They will also
support the further development of trainee research
networks and work with relevant stakeholders to promote
and increase opportunities for trainees.
The post is supported by the cost of one period of
professional activity (1 PA) per week; back-filled to the
post-holder’s employing Trust/Health Board, to enable the
successful candidate to dedicate a minimum of 4 hours per
week to the role.
You can download a full Job Description and Person
Specification for this role and find out more information
from the NIAA website: www.niaa.org.uk.
Deadline for applications: Friday, 29 July 2016 at 12 noon
Interviews will take place in September 2016
Closing date: 19 September 2016
IRCTravelGrantsJULY.indd 1
NIAA Vacancy:
Academic Training
Coordinator
Obstetric Anaesthetists’ Association
Promoting the highest standards of anaesthetic practice in the care of mother and baby
Three Day Course
in Obstetric Anaesthesia
SAVE THE DATE
Monday 7 – Wednesday 9 November 2016
Venue: Church House Conference Centre, Westminster, London
The OAA’s annual ‘state of the art’ course,
held over three days in the spectacular
setting of Church House, Westminster
Save
the date
Maternal
Critical Care
Royal College of Physicians,
London
For further information
on OAA events, please visit:
CLINICAL AND ORGANISATIONAL TOPICS,
EXPERT PANEL DISCUSSION
www.oaa-anaes.ac.uk
www.oaa-anaes.ac.uk
SPEAKERS
PROF PHILIP HESS, BOSTON
PROF KHALID KHAN, UK
PROF CRISTIAN ARZOLA, TORONTO
PROF THIERRY GIRARD, BASEL
DR ROBIN RUSSELL, UK
KEYNOTE LECTURE
PROF STEVE YENTIS
Complimentary
Drinks Reception
& Networking
Trainee forum
Ultrasound workshop
www.oaa-anaes.ac.uk
ANNUAL CONGRESS
BIRMINGHAM
14 -16 September 2016
LAST CHAN E
FOR A AGBI MEC
EARLY-BIRD DISC MBER
OUNTS
Join your peers and the international anaesthesia
community at this year’s AAGBI Annual Congress
Keynotes:
Andy McCann, Performance Coach, DNA Definitive – Walking the tightrope:
dynamic resilience in action
Professor Alistair Burns, Manchester – Dementia: a challenge for everyone
Professor Paul Myles, Melbourne – Quality of recovery and disability-free survival
Plus, scientific topics, practical workshops,
social events and more!
European
Accreditation Council
for Continuing
Medical Education
(EACCME)
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